Standard with Step Therapy Formulary

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&'if Arkansas & 'if BlueAdvantage T. ~ BlueCross BlueShield T. 'VI Administrators of Arkansas

Arkansas Blue Cross and Blue Shield Standard with Step Therapy and Tier 4 Specialty Formulary

(10/01/2021)

INTRODUCTION ...... 4 PREFACE ...... 4 PHARMACY AND THERAPEUTICS (P&T) COMMITTEE ...... 5 DRUG LIST PRODUCT DESCRIPTIONS...... 5 GENERIC SUBSTITUTION ...... 5 LEGEND ...... 6 ANALGESICS ...... 7 COX-2 INHIBITORS ...... 7 GOUT ...... 7 NSAIDs ...... 7 NSAIDs, COMBINATIONS ...... 7 NSAIDs, TOPICAL ...... 7 OPIOID ANALGESICS ...... 7 ANTI-INFECTIVES ...... 8 ANTIBACTERIALS ...... 8 ANTIFUNGALS ...... 9 ANTIMALARIALS ...... 9 ANTIRETROVIRAL AGENTS ...... 9 ANTITUBERCULAR AGENTS ...... 10 ANTIVIRALS ...... 10 MISCELLANEOUS ...... 11 ANTINEOPLASTIC AGENTS ...... 11 ALKYLATING AGENTS ...... 12 ANTIMETABOLITES ...... 12 BIOSIMILARS ...... 12 HORMONAL ANTINEOPLASTIC AGENTS...... 12 KINASE INHIBITORS ...... 12 MONOCLONAL ANTIBODIES ...... 13 MULTIPLE MYELOMA ...... 13 PROSTATE CANCER ...... 13 TOPOISOMERASE INHIBITORS ...... 13 MISCELLANEOUS ...... 13 CARDIOVASCULAR ...... 14 ACE INHIBITORS ...... 14 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ...... 14 ACE INHIBITOR/DIURETIC COMBINATIONS ...... 14 ADRENOLYTICS, CENTRAL ...... 14 ALDOSTERONE RECEPTOR ANTAGONISTS ...... 14 ALPHA BLOCKERS ...... 14 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ...... 15 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS ...... 15 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS ...... 15 ANTIARRHYTHMICS ...... 15 ANTILIPEMICS ...... 15 BETA-BLOCKERS ...... 16 BETA-BLOCKER/DIURETIC COMBINATIONS...... 17 CALCIUM CHANNEL BLOCKERS ...... 17 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS ...... 17 DIGITALIS GLYCOSIDES ...... 17 DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS ...... 17 DIURETICS ...... 17 HEART FAILURE ...... 18 NITRATES ...... 18 PULMONARY ARTERIAL HYPERTENSION ...... 18 MISCELLANEOUS ...... 19

CENTRAL NERVOUS SYSTEM ...... 19 ANTIANXIETY ...... 19 ANTICONVULSANTS ...... 19 ANTIDEMENTIA...... 20 ANTIDEPRESSANTS ...... 20 ANTIPARKINSONIAN AGENTS ...... 21 ANTIPSYCHOTICS ...... 21 ATTENTION DEFICIT HYPERACTIVITY DISORDER ...... 22 FIBROMYALGIA ...... 22 HYPNOTICS ...... 22 MIGRAINE ...... 22 MOOD STABILIZERS ...... 23 MOVEMENT DISORDERS ...... 23 MULTIPLE SCLEROSIS AGENTS ...... 23 MUSCULOSKELETAL THERAPY AGENTS ...... 24 MYASTHENIA GRAVIS ...... 24 NARCOLEPSY ...... 24 POSTHERPETIC NEURALGIA (PHN) ...... 24 PSYCHOTHERAPEUTIC-MISCELLANEOUS ...... 24 ENDOCRINE AND METABOLIC ...... 25 ACROMEGALY ...... 25 ANDROGENS ...... 25 ANTIDIABETICS ...... 26 CALCIUM RECEPTOR ANTAGONISTS ...... 28 CALCIUM REGULATORS ...... 28 CARNITINE DEFICIENCY AGENTS ...... 28 CENTRAL PRECOCIOUS PUBERTY ...... 28 CONTRACEPTIVES ...... 28 ENDOMETRIOSIS ...... 29 FERTILITY REGULATORS ...... 29 GAUCHER DISEASE ...... 30 GLUCOCORTICOIDS ...... 30 GLUCOSE ELEVATING AGENTS ...... 30 HEREDITARY TYROSINEMIA TYPE 1 AGENTS ...... 30 HUMAN GROWTH HORMONES ...... 30 HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS ...... 30 MENOPAUSAL SYMPTOM AGENTS ...... 30 PHENYLKETONURIA TREATMENT AGENTS ...... 31 PHOSPHATE BINDER AGENTS ...... 31 POLYNEUROPATHY ...... 31 POTASSIUM-REMOVING AGENTS ...... 31 PROGESTINS ...... 31 SELECTIVE ESTROGEN RECEPTOR MODULATORS ...... 31 THYROID AGENTS ...... 31 UTERINE FIBROIDS...... 32 VASOPRESSINS ...... 32 MISCELLANEOUS ...... 32 GASTROINTESTINAL ...... 32 ANTIDIARRHEALS ...... 32 ANTIEMETICS ...... 32 ANTISPASMODICS ...... 32 CHOLELITHOLYTICS ...... 32 H2 RECEPTOR ANTAGONISTS ...... 32 INFLAMMATORY BOWEL DISEASE ...... 32 IRRITABLE BOWEL SYNDROME ...... 33 LAXATIVES ...... 33 OPIOID-INDUCED CONSTIPATION ...... 33 PANCREATIC ENZYMES ...... 33 PROSTAGLANDINS ...... 33 PROTON PUMP INHIBITORS ...... 33 SALIVA STIMULANTS ...... 33 STEROIDS, RECTAL ...... 33 ULCER THERAPY COMBINATIONS ...... 34 MISCELLANEOUS ...... 34

GENITOURINARY ...... 34 BENIGN PROSTATIC HYPERPLASIA ...... 34 URINARY ANTISPASMODICS ...... 34 VAGINAL ANTI-INFECTIVES ...... 34 MISCELLANEOUS ...... 34 HEMATOLOGIC ...... 34 ANTICOAGULANTS ...... 34 CHELATING AGENTS ...... 35 HEMATOPOIETIC GROWTH FACTORS ...... 35 HEMOPHILIA A AGENTS ...... 35 HEMOPHILIA B AGENTS ...... 35 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS ...... 35 PLATELET AGGREGATION INHIBITORS ...... 35 PLATELET SYNTHESIS INHIBITORS ...... 36 STEM CELL MOBILIZERS ...... 36 THROMBOCYTOPENIA AGENTS ...... 36 MISCELLANEOUS ...... 36 IMMUNOLOGIC AGENTS ...... 36 ALLERGENIC EXTRACTS ...... 36 AUTOIMMUNE AGENTS (PHYSICIAN-ADMINISTERED) ...... 36 AUTOIMMUNE AGENTS (SELF-ADMINISTERED) ‡ ...... 36 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) ...... 36 HEREDITARY ANGIOEDEMA ...... 36 IMMUNOMODULATORS ...... 36 IMMUNOSUPPRESSANTS ...... 37 NUTRITIONAL/SUPPLEMENTS ...... 37 ELECTROLYTES ...... 37 VITAMINS AND MINERALS ...... 37 RESPIRATORY ...... 38 ALPHA-1 ANTITRYPSIN DEFICIENCY AGENTS ...... 38 ANAPHYLAXIS TREATMENT AGENTS ...... 38 ANTICHOLINERGICS ...... 38 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ...... 38 ANTICHOLINERGIC/BETA AGONIST/STEROID INHALANT COMBINATIONS ...... 38 ANTIHISTAMINES, LOW SEDATING ...... 38 ANTIHISTAMINES, SEDATING ...... 38 ANTITUSSIVES ...... 38 ANTITUSSIVE COMBINATIONS ...... 39 BETA AGONISTS ...... 39 CYSTIC FIBROSIS ...... 39 LEUKOTRIENE MODULATORS ...... 39 MAST CELL STABILIZERS ...... 39 NASAL ANTIHISTAMINES ...... 39 NASAL STEROIDS/COMBINATIONS ...... 40 PHOSPHODIESTERASE-4 INHIBITORS...... 40 PULMONARY FIBROSIS AGENTS ...... 40 SEVERE ASTHMA AGENTS ...... 40 STEROID/BETA AGONIST COMBINATIONS ...... 40 STEROID INHALANTS ...... 40 XANTHINES ...... 40 MISCELLANEOUS ...... 40 TOPICAL ...... 40 DERMATOLOGY ...... 40 MOUTH/THROAT/DENTAL AGENTS ...... 43 OPHTHALMIC ...... 43 OTIC ...... 45 WEBSITES ...... 46 INDEX ...... 48

INTRODUCTION We are pleased to provide the 2021 Arkansas Blue Cross and Blue Shield Standard with Step Therapy and Tier 4 Specialty Formulary as a useful reference and informational tool. The Standard with Step Therapy and Tier 4 Specialty Formulary can assist practitioners in selecting clinically appropriate and cost-effective products for their patients.

The drugs represented have been reviewed by a National Pharmacy and Therapeutics (P&T) Committee and are approved for inclusion. The Standard with Step Therapy and Tier 4 Specialty Formulary is reflective of current medical practice as of the date of review.

The information contained in this Standard with Step Therapy and Tier 4 Specialty Formulary and its appendices is provided solely for the convenience of medical providers. We do not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. This Standard with Step Therapy and Tier 4 Specialty Formulary is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in his or her choice of prescription drugs. All the information in the Standard with Step Therapy and Tier 4 Specialty Formulary is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable.

We assume no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer's product literature or standard references for more detailed information.

National guidelines can be found on the National Guideline Clearinghouse site at https://ahrq.gov.gam/, on the websites listed under each therapeutic class and on the sites listed in the WEBSITES section of this publication. PREFACE The Standard with Step Therapy and Tier 4 Specialty Formulary is organized by sections. Each section is divided by therapeutic drug class primarily defined by mechanism of action. Products are listed by generic name with brand name for reference only. Unless exceptions are noted, generally all applicable dosage forms and strengths of the drug cited are included in the Standard with Step Therapy and Tier 4 Specialty Formulary. Generics should be considered the first line of prescribing.

Individual pharmacy benefit plans may impose restrictions or not reimburse some products. In addition, over-the- counter (OTC) products, with the exception of insulin and diabetes monitoring products, are usually not included in the pharmacy benefit. Pharmacy law requires a valid prescription for the purchase of needles and syringes in certain states. OTC products are listed for informational purposes. If covered in the pharmacy benefit, OTC products require a valid prescription.

Drugs represented in the Standard with Step Therapy and Tier 4 Specialty Formulary may have varying cost to the plan member. Prescription benefit plan may alter coverage of certain products or vary copay amounts based on the condition being treated. Generic medications typically are available at the lowest cost, brand-name medications on the Standard with Step Therapy and Tier 4 Specialty Formulary will generally cost more than generics, and brand- name medications not on the list will generally cost the most.

The tiered format places drugs into tiers or levels of cost sharing by the plan member in the following manner:

Tier 1: Lowest plan member copayment: All generic, non-specialty drugs, including those on the Standard with Step Therapy and Tier 4 Specialty Formulary. Tier 2: Intermediate plan member copayment: Preferred brand-name products on the Standard with Step Therapy and Tier 4 Specialty Formulary selected for Tier 2. Tier 3: Higher plan member copayment: Products on the Standard with Step Therapy and Tier 4 Specialty Formulary not selected for Tier 2, and all non-specialty, non-preferred, brand-name products. In most cases, there will be reasonable alternatives in Tier 1 or Tier 2 for products found in this higher tier. Tier 4: Highest plan member copayment. Specialty products are at Tier 4.

PHARMACY AND THERAPEUTICS (P&T) COMMITTEE The services of an independent National Pharmacy and Therapeutics Committee ("P&T Committee") are utilized to approve safe and clinically effective drug therapies. The P&T Committee is an external advisory body of clinical professionals from across the United States. The P&T Committee's voting members include physicians, pharmacists, a pharmacoeconomist and a medical ethicist, all of whom have a broad background of clinical and academic expertise regarding prescription drugs. Employees with significant clinical expertise are invited to meet with the P&T Committee, but no employee may vote on issues before the P&T Committee. Voting members of the P&T Committee must disclose any financial relationship or conflicts of interest with any pharmaceutical manufacturers.

Arkansas Blue Cross will utilize the services of the independent National P&T Committee as well as internal pharmacy and medical advisory committees to direct formulary decisions as it relates to our benefit certificates and policies. DRUG LIST PRODUCT DESCRIPTIONS To assist in understanding which specific strengths and dosage forms are on the Standard with Step Therapy and Tier 4 Specialty Formulary, examples are noted below. The general principles shown in the examples can usually be extended to other entries in the book. Any exceptions are noted.

Products on the Standard with Step Therapy and Tier 4 Specialty Formulary include all strengths and dosage forms of the cited brand-name product. cefixime Suprax Oral capsules, oral chewable tablets, oral suspension and all strengths of Suprax would be included in this listing.

When a strength or dosage form is specified, only the specified strength and dosage form is on the Standard with Step Therapy and Tier 4 Specialty Formulary. Other strengths/dosage forms of the reference product are not. tizanidine tabs Zanaflex The tablets of Zanaflex are on the Standard with Step Therapy and Tier 4 Specialty Formulary. From this entry, the capsules cannot be assumed to be on the list unless there is a specific entry.

Extended-release and delayed-release products require their own entry. sitagliptin/metformin Janumet The immediate-release product listing of Janumet alone would not include the extended-release product Janumet XR.

sitagliptin/metformin ext-rel Janumet XR A separate entry for Janumet XR confirms that the extended-release product is on the Standard with Step Therapy and Tier 4 Specialty Formulary.

Dosage forms on the Standard with Step Therapy and Tier 4 Specialty Formulary will be consistent with the category and use where listed. nystatin The above nystatin entry listed in the TOPICAL/DERMATOLOGY section is limited to the topical dosage forms. From this entry the oral formulations cannot be assumed to be on the list unless there is an entry for this product in the ANTI- INFECTIVES section of the Standard with Step Therapy and Tier 4 Specialty Formulary.

GENERIC SUBSTITUTION Generic substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand-name product. Boldface type indicates generic availability. However, not all strengths or dosage forms of the generic name in boldface type may be generically available. In addition, boldface type may indicate that the brand name cited is a generic. Examples of the latter include Levoxyl and Trivora.

One way to reduce out-of-pocket cost is by requesting a generic drug. Generic drugs are usually priced lower than their brand-name equivalents. Prescription generic drugs are:

• Approved by the U.S. Food and Drug Administration for safety and effectiveness, and are manufactured under the same strict standards that apply to brand-name drugs. • Tested in humans to assure the generic is absorbed into the bloodstream in a similar rate and extent compared to the brand-name drug. Generics may be different from the brand in size, color, and inactive ingredients, but this does not alter their effectiveness or ability to be absorbed just like the brand-name drug. • Manufactured in the same strength and dosage form as the brand-name drugs.

When a generic drug is substituted for a brand-name drug, you can expect the generic to produce the same clinical effect and safety profile as the brand-name drug. Brand-name drugs having a generic available may:

• Incur higher copayment (tier 3) • Require payment of the difference in price between generic and brand, in addition to copayment • Require mandatory generic dispensing LEGEND † Coverage determined under the Medical Benefit OTC Over the Counter PA Prior Authorization QL Quantity Limit SGM Specialty Guideline Management ST Step Therapy boldface Indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name delayed-rel Delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification ext-rel Extended-release (also known as sustained-release), refer to the reference brand listed for clarification

ANALGESICS Practice guidelines of pain management are available at: https://www.asahq.org

COX-2 INHIBITORS celecoxib Tier 1

GOUT allopurinol Tier 1 colchicine tabs Tier 1 probenecid Tier 1

NSAIDs diclofenac sodium delayed-rel Tier 1 diflunisal Tier 1 ibuprofen Tier 1 meloxicam tablet Tier 1 nabumetone Tier 1 naproxen sodium tabs Tier 1 naproxen tabs Tier 1 oxaprozin Tier 1 sulindac Tier 1

NSAIDs, COMBINATIONS diclofenac sodium delayed-rel/misoprostol Tier 1

NSAIDs, TOPICAL PA diclofenac sodium gel 1% Tier 1 diclofenac sodium soln Tier 1

OPIOID ANALGESICS Practice Guidelines for Cancer Pain Management (includes WHO analgesic ladder) are available at: https://www.asahq.org https://www.nccn.org

Opioid guidelines in the management of chronic non-malignant pain are available at: https://www.asipp.org/ASIPP-Guidelines.html

QL buprenorphine transdermal Tier 1 QL codeine/acetaminophen Tier 1 QL fentanyl transdermal Tier 1 PA fentanyl transmucosal lozenge Tier 1 QL hydrocodone ext-rel Tier 1 QL hydrocodone/acetaminophen Tier 1 QL hydromorphone Tier 1 QL hydromorphone ext-rel Tier 1 QL methadone Tier 1 QL morphine Tier 1 QL morphine ext-rel Tier 1 QL morphine supp Tier 1 QL oxycodone caps 5 mg Tier 1 QL oxycodone concentrate 20 mg/mL Tier 1 QL oxycodone soln 5 mg/5 mL Tier 1 Tier 1 - Generics, Tier 2 – Preferred Brands, Tier 3 – Non-Preferred Brands boldface - indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name † - Coverage determined under the Medical Benefit, OTC – Over the Counter, PA – Prior Authorization, QL – Quantity Limit SGM – Specialty Guideline Management (*may require additional copay and/or PA), ST – Step Therapy

QL oxycodone tabs 5 mg, 15 mg, 30 mg Tier 1 QL oxycodone/acetaminophen 5/325 Tier 1 QL, * tramadol Tier 1 QL tramadol ext-rel tablet Tier 1 QL buprenorphine Tier 2 BELBUCA PA fentanyl sublingual spray Tier 2 SUBSYS QL oxycodone ext-rel Tier 2 XTAMPZA ER QL tapentadol Tier 2 NUCYNTA QL tapentadol ext-rel Tier 2 NUCYNTA ER

* Listing does not include NDC 52817019610. Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package size.

ANTI-INFECTIVES Practice guidelines and statements developed and endorsed by the Infectious Diseases Society of America are available at: https://www.idsociety.org

Hepatitis: CDC recommendations on the treatment of hepatitis are available at: https://www.cdc.gov/hepatitis/Resources/

Guidelines for the management of chronic hepatitis by the American Association for the Study of Liver Disease are available at: https://www.aasld.org

HIV/AIDS: Guidelines for the treatment of HIV patients by the U.S. Department of Health and Human Services are available at: https://www.aidsinfo.nih.gov

Infective Endocarditis: American Heart Association recommendations for the prevention of bacterial endocarditis are available at: https://professional.heart.org

Influenza: Recommendations of the Advisory Committee on Immunization Practices are available at: https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html

International Travel: CDC recommendations for international travel are available at: https://wwwnc.cdc.gov/travel

Respiratory Tract Infection/Antibiotic Use/Community Acquired Pneumonia/Other: Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infection in adults are available at: https://www.cdc.gov/pneumonia/management-prevention-guidelines.html

Sexually Transmitted Diseases: CDC Sexually Transmitted Diseases Guidelines are available at: https://www.cdc.gov/std/treatment/default.htm

ANTIBACTERIALS Cephalosporins First Generation cefadroxil Tier 1 cephalexin Tier 3 KEFLEX Second Generation cefprozil Tier 1 cefuroxime axetil Tier 1

Tier 1 - Generics, Tier 2 – Preferred Brands, Tier 3 – Non-Preferred Brands boldface - indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name † - Coverage determined under the Medical Benefit, OTC – Over the Counter, PA – Prior Authorization, QL – Quantity Limit SGM – Specialty Guideline Management (*may require additional copay and/or PA), ST – Step Therapy

Third Generation cefdinir Tier 1 cefixime Tier 2 SUPRAX

Erythromycins/Macrolides clarithromycin Tier 1 clarithromycin ext-rel Tier 1 erythromycin delayed-rel Tier 1 erythromycin ethylsuccinate Tier 1 erythromycin stearate Tier 1 ST, QL fidaxomicin Tier 2 DIFICID azithromycin Tier 3 ZITHROMAX

Fluoroquinolones levofloxacin Tier 1 moxifloxacin Tier 1 ciprofloxacin Tier 3 CIPRO

Penicillins amoxicillin Tier 1 amoxicillin/clavulanate ext-rel Tier 1 ampicillin Tier 1 dicloxacillin Tier 1 penicillin VK Tier 1 amoxicillin/clavulanate Tier 3 AUGMENTIN

Tetracyclines doxycycline hyclate 20 mg Tier 1 minocycline Tier 1 tetracycline Tier 1 PA doxycycline hyclate Tier 3 VIBRAMYCIN

ANTIFUNGALS clotrimazole troches Tier 1 griseofulvin ultramicrosize Tier 1 PA itraconazole Tier 1 nystatin Tier 1 terbinafine tabs Tier 1 PA voriconazole Tier 2 VFEND fluconazole Tier 3 DIFLUCAN

ANTIMALARIALS chloroquine Tier 1 mefloquine Tier 1 atovaquone/proguanil Tier 2 MALARONE

ANTIRETROVIRAL AGENTS Antiretroviral Combinations QL efavirenz/emtricitabine/tenofovir disoproxil fumarate Tier 1 QL efavirenz/lamivudine/tenofovir disoproxil fumarate Tier 1 QL emtricitabine/tenofovir disoproxil fumarate Tier 1 QL lamivudine/zidovudine Tier 1 QL abacavir/dolutegravir/lamivudine Tier 2 TRIUMEQ

QL atazanavir/cobicistat Tier 2 EVOTAZ QL bictegravir/emtricitabine/tenofovir alafenamide Tier 2 BIKTARVY QL darunavir/cobicistat Tier 2 PREZCOBIX QL darunavir/cobicistat/emtricitabine/tenofovir alafenamide Tier 2 SYMTUZA QL dolutegravir/lamivudine Tier 2 DOVATO QL elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide Tier 2 GENVOYA QL elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate Tier 2 STRIBILD QL emtricitabine/rilpivirine/tenofovir alafenamide Tier 2 ODEFSEY QL emtricitabine/rilpivirine/tenofovir disoproxil fumarate Tier 2 COMPLERA QL emtricitabine/tenofovir alafenamide Tier 2 DESCOVY QL lamivudine/tenofovir disoproxil fumarate Tier 2 CIMDUO QL lamivudine/tenofovir disoproxil fumarate Tier 2 TEMIXYS QL abacavir/lamivudine Tier 3 EPZICOM

Fusion Inhibitors QL enfuvirtide Tier 2 FUZEON

Integrase Inhibitors QL dolutegravir Tier 2 TIVICAY QL raltegravir Tier 2 ISENTRESS

Non-nucleoside Reverse Transcriptase Inhibitors QL efavirenz Tier 1 QL nevirapine Tier 1 QL nevirapine ext-rel Tier 1 QL etravirine Tier 2 INTELENCE QL rilpivirine Tier 2 EDURANT

Nucleoside Reverse Transcriptase Inhibitors QL abacavir Tier 1 QL lamivudine Tier 1 QL stavudine Tier 1 QL emtricitabine Tier 2 EMTRIVA QL zidovudine Tier 2 RETROVIR

Nucleotide Reverse Transcriptase Inhibitors QL tenofovir disoproxil fumarate Tier 2 VIREAD

Protease Inhibitors QL lopinavir/ritonavir Tier 1 QL atazanavir Tier 2 QL darunavir Tier 2 PREZISTA QL ritonavir Tier 2 NORVIR

ANTITUBERCULAR AGENTS isoniazid Tier 1 pyrazinamide Tier 1 ethambutol Tier 2 MYAMBUTOL rifampin Tier 2 RIFADIN

ANTIVIRALS Cytomegalovirus Agents valganciclovir Tier 1

Hepatitis Agents Hepatitis B entecavir tabs Tier 1 lamivudine Tier 1 entecavir soln Tier 2 BARACLUDE tenofovir alafenamide Tier 2 VEMLIDY

Hepatitis C *, SGM ledipasvir/sofosbuvir Tier 4 HARVONI SGM ribavirin Tier 4 *, SGM sofosbuvir/velpatasvir Tier 4 EPCLUSA *, SGM sofosbuvir/velpatasvir/voxilaprevir Tier 4 VOSEVI

* HARVONI only for genotypes 1, 4, 5, and 6 EPCLUSA for genotypes 1, 2, 3, 4, 5, 6 VOSEVI for use in patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1-6) or sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3)

Herpes Agents acyclovir caps, tabs Tier 1 famciclovir Tier 1 valacyclovir Tier 1

Influenza Agents QL oseltamivir Tier 1 QL zanamivir Tier 2 RELENZA

MISCELLANEOUS dapsone Tier 1 PA linezolid Tier 1 nitrofurantoin macrocrystals Tier 1 * nitrofurantoin susp Tier 1 PA pyrimethamine Tier 1 sulfamethoxazole/trimethoprim Tier 1 sulfamethoxazole/trimethoprim DS Tier 1 tinidazole Tier 1 trimethoprim Tier 1 clindamycin Tier 2 CLEOCIN mebendazole chewable Tier 2 EMVERM nitrofurantoin ext-rel Tier 2 MACROBID PA rifaximin 550 mg Tier 2 XIFAXAN QL vancomycin caps Tier 2 VANCOCIN ivermectin Tier 3 STROMECTOL metronidazole Tier 3 FLAGYL

* Listing does not include NDC 70408023932. Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package size.

ANTINEOPLASTIC AGENTS Clinical practice guidelines in oncology are available at: https://www.asco.org https://www.nccn.org Tier 1 - Generics, Tier 2 – Preferred Brands, Tier 3 – Non-Preferred Brands boldface - indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name † - Coverage determined under the Medical Benefit, OTC – Over the Counter, PA – Prior Authorization, QL – Quantity Limit SGM – Specialty Guideline Management (*may require additional copay and/or PA), ST – Step Therapy

ALKYLATING AGENTS cyclophosphamide caps Tier 1 busulfan Tier 2 MYLERAN chlorambucil Tier 2 LEUKERAN melphalan Tier 2 ALKERAN SGM temozolomide Tier 4 TEMODAR

ANTIMETABOLITES mercaptopurine Tier 1 methotrexate Tier 2 TREXALL thioguanine Tier 2 TABLOID SGM capecitabine Tier 4 XELODA SGM trifluridine/tipiracil Tier 4 LONSURF

BIOSIMILARS † bevacizumab-bvzr ZIRABEV † rituximab-pvvr RUXIENCE † trastuzumab-anns KANJINTI † trastuzumab-qyyp TRAZIMERA

HORMONAL ANTINEOPLASTIC AGENTS Antiandrogens flutamide Tier 1 bicalutamide Tier 3 CASODEX SGM abiraterone Tier 4 SGM abiraterone Tier 4 YONSA SGM apalutamide Tier 4 ERLEADA SGM darolutamide Tier 4 NUBEQA SGM enzalutamide Tier 4 XTANDI

Antiestrogens tamoxifen Tier 1

Aromatase Inhibitors anastrozole Tier 2 ARIMIDEX exemestane Tier 2 AROMASIN letrozole Tier 2 FEMARA

Progestins megestrol acetate tabs Tier 1

KINASE INHIBITORS SGM acalabrutinib Tier 4 CALQUENCE SGM alectinib Tier 4 ALECENSA SGM bosutinib Tier 4 BOSULIF SGM brigatinib Tier 4 ALUNBRIG SGM cabozantinib Tier 4 CABOMETYX SGM dasatinib Tier 4 SPRYCEL SGM duvelisib Tier 4 COPIKTRA SGM erlotinib Tier 4 SGM everolimus Tier 4 AFINITOR SGM gefitinib Tier 4 IRESSA

SGM gilteritinib Tier 4 XOSPATA SGM imatinib mesylate Tier 4 SGM lapatinib Tier 4 SGM midostaurin Tier 4 RYDAPT SGM osimertinib Tier 4 TAGRISSO SGM palbociclib Tier 4 IBRANCE SGM pazopanib Tier 4 VOTRIENT SGM regorafenib Tier 4 STIVARGA SGM ribociclib Tier 4 KISQALI SGM ribociclib + letrozole Tier 4 KISQALI FEMARA CO-PACK SGM selumetinib Tier 4 KOSELUGO SGM sunitinib Tier 4 SUTENT

MONOCLONAL ANTIBODIES † pertuzumab PERJETA SGM pertuzumab/trastuzumab/hyaluronidase-zzxf Tier 4 PHESGO

MULTIPLE MYELOMA Immunomodulators SGM lenalidomide Tier 4 REVLIMID SGM pomalidomide Tier 4 POMALYST SGM thalidomide Tier 4 THALOMID

Proteasome Inhibitors † bortezomib VELCADE SGM ixazomib Tier 4 NINLARO

PROSTATE CANCER Luteinizing Hormone-Releasing Hormone (LHRH) Agonists † leuprolide acetate † leuprolide acetate ELIGARD

Luteinizing Hormone-Releasing Hormone (LHRH) Antagonists † degarelix acetate FIRMAGON

TOPOISOMERASE INHIBITORS SGM topotecan caps Tier 4 HYCAMTIN MISCELLANEOUS etoposide Tier 1 tretinoin caps Tier 1 hydroxyurea Tier 2 HYDREA mitotane Tier 2 LYSODREN procarbazine Tier 2 MATULANE SGM bexarotene caps Tier 4 TARGRETIN SGM niraparib Tier 4 ZEJULA SGM olaparib Tier 4 LYNPARZA SGM rucaparib Tier 4 RUBRACA SGM sonidegib Tier 4 ODOMZO SGM vismodegib Tier 4 ERIVEDGE SGM vorinostat Tier 4 ZOLINZA

CARDIOVASCULAR The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure is available at: https://jamanetwork.com/journals/jama/fullarticle/1791497

Guidelines for the evaluation and management of cardiovascular diseases in adults are available at: https://www.acc.org https://professional.heart.org

ACE INHIBITORS Guidelines for the use of ACE inhibitors are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://professional.diabetes.org https://www.acc.org https://professional.heart.org

captopril Tier 1 fosinopril Tier 1 perindopril Tier 1 trandolapril Tier 1 benazepril Tier 3 LOTENSIN enalapril Tier 3 VASOTEC lisinopril Tier 3 ZESTRIL quinapril Tier 3 ACCUPRIL ramipril Tier 3 ALTACE

ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/benazepril Tier 2 LOTREL trandolapril/verapamil ext-rel Tier 2 TARKA

ACE INHIBITOR/DIURETIC COMBINATIONS captopril/hydrochlorothiazide Tier 1 fosinopril/hydrochlorothiazide Tier 1 lisinopril/hydrochlorothiazide Tier 1 benazepril/hydrochlorothiazide Tier 3 LOTENSIN HCT enalapril/hydrochlorothiazide Tier 3 VASERETIC quinapril/hydrochlorothiazide Tier 3 ACCURETIC ADRENOLYTICS, CENTRAL clonidine Tier 1 guanfacine Tier 1 clonidine transdermal Tier 2 CATAPRES-TTS

ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone Tier 2 INSPRA spironolactone Tier 2 ALDACTONE

ALPHA BLOCKERS Guidelines for the use of alpha blockers in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497

terazosin Tier 1 doxazosin Tier 3 CARDURA

ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS Guidelines for the use of angiotensin II receptor antagonists in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://professional.diabetes.org

candesartan Tier 1 candesartan/hydrochlorothiazide Tier 1 irbesartan Tier 1 irbesartan/hydrochlorothiazide Tier 1 losartan Tier 1 losartan/hydrochlorothiazide Tier 1 olmesartan Tier 1 olmesartan/hydrochlorothiazide Tier 1 telmisartan Tier 1 telmisartan/hydrochlorothiazide Tier 1 valsartan Tier 1 valsartan/hydrochlorothiazide Tier 1

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/olmesartan Tier 1 amlodipine/telmisartan Tier 1 amlodipine/valsartan Tier 1

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS amlodipine/valsartan/hydrochlorothiazide Tier 1 olmesartan/amlodipine/hydrochlorothiazide Tier 3 TRIBENZOR

ANTIARRHYTHMICS Guidelines for the use of antiarrhythmics and cardiac glycosides in various patient populations are available at: https://www.acc.org

amiodarone Tier 1 disopyramide Tier 1 flecainide Tier 1 propafenone Tier 1 sotalol Tier 1 disopyramide ext-rel Tier 2 NORPACE CR dronedarone Tier 2 MULTAQ propafenone ext-rel Tier 2 RYTHMOL SR dofetilide Tier 4 TIKOSYN

ANTILIPEMICS The 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol is available at: https://www.ahajournals.org/doi/10.1161/CIR.0000000000000625

ACL Inhibitors/Combinations PA bempedoic acid Tier 2 NEXLETOL PA bempedoic acid/ezetimibe Tier 2 NEXLIZET

Bile Acid Resins colesevelam Tier 1

cholestyramine Tier 3 QUESTRAN/QUESTRAN LIGHT colestipol Tier 3 COLESTID

Cholesterol Absorption Inhibitors ezetimibe Tier 1

Fibrates * fenofibrate Tier 1 fenofibric acid delayed-rel Tier 3 TRILIPIX gemfibrozil Tier 3 LOPID

* Listing does not include fenofibrate capsule 50 mg, 130 mg; fenofibrate tablet 40 mg, 120mg.

HMG-CoA Reductase Inhibitors/Combinations atorvastatin Tier 1 fluvastatin Tier 1 lovastatin Tier 1 pravastatin Tier 1 rosuvastatin Tier 1 ezetimibe/simvastatin Tier 3 VYTORIN simvastatin Tier 3 ZOCOR

Niacins niacin ext-rel Tier 3 NIASPAN

Omega-3 Fatty Acids PA icosapent ethyl Tier 2 VASCEPA PA omega-3 acid ethyl esters Tier 3 LOVAZA

PCSK9 Inhibitors PA alirocumab Tier 2 PRALUENT

BETA-BLOCKERS Guidelines for the use of beta-blockers and beta-blocker combinations in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://www.acc.org

atenolol Tier 1 bisoprolol Tier 1 carvedilol phosphate ext-rel Tier 1 labetalol Tier 1 metoprolol succinate ext-rel Tier 1 metoprolol tartrate Tier 1 pindolol Tier 1 propranolol Tier 1 propranolol ext-rel Tier 1 nebivolol Tier 2 BYSTOLIC carvedilol Tier 3 COREG nadolol Tier 3 CORGARD

BETA-BLOCKER/DIURETIC COMBINATIONS Guidelines for the use of beta-blockers and diuretic combinations in various patient populations are available at: https://jamanetwork.com/journals/jama/fullarticle/1791497 https://www.acc.org

atenolol/chlorthalidone Tier 1 metoprolol/hydrochlorothiazide Tier 1 bisoprolol/hydrochlorothiazide Tier 2 ZIAC

CALCIUM CHANNEL BLOCKERS Dihydropyridines amlodipine Tier 1 felodipine ext-rel Tier 1 nifedipine ext-rel Tier 1 nifedipine ext-rel Tier 3 PROCARDIA XL

Nondihydropyridines * diltiazem ext-rel Tier 1 diltiazem ext-rel Tier 3 TIAZAC verapamil ext-rel Tier 3 CALAN SR

* Listing does not include generics for CARDIZEM LA.

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine/atorvastatin Tier 3 CADUET

DIGITALIS GLYCOSIDES digoxin 0.125 mg, 0.25 mg Tier 1 digoxin ped elixir Tier 1 digoxin 0.0625 mg, 0.1875 mg Tier 2 LANOXIN

DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS aliskiren Tier 1 ST aliskiren/hydrochlorothiazide Tier 2 TEKTURNA HCT

DIURETICS Carbonic Anhydrase Inhibitors acetazolamide Tier 1 acetazolamide ext-rel Tier 1 methazolamide Tier 1

Diuretic Combinations amiloride/hydrochlorothiazide Tier 1 triamterene/hydrochlorothiazide Tier 1 spironolactone/hydrochlorothiazide Tier 3 ALDACTAZIDE triamterene/hydrochlorothiazide Tier 3 MAXZIDE

Loop Diuretics bumetanide Tier 1 torsemide Tier 1 furosemide Tier 3 LASIX

Potassium-sparing Diuretics amiloride Tier 1 triamterene Tier 1

Thiazides and Thiazide-like Diuretics chlorthalidone Tier 1 hydrochlorothiazide Tier 1 indapamide Tier 1 metolazone Tier 1

HEART FAILURE isosorbide dinitrate/hydralazine Tier 2 BIDIL ivabradine Tier 2 CORLANOR sacubitril/valsartan Tier 2 ENTRESTO

NITRATES Oral * isosorbide dinitrate Tier 1 isosorbide mononitrate Tier 1 isosorbide mononitrate ext-rel Tier 1

* Listing does not include isosorbide dinitrate 40 mg.

Sublingual/Translingual nitroglycerin lingual spray Tier 3 NITROLINGUAL nitroglycerin sublingual Tier 3 NITROSTAT

Transdermal nitroglycerin transdermal Tier 1 nitroglycerin transdermal Tier 2 NITRO-DUR

PULMONARY ARTERIAL HYPERTENSION Endothelin Receptor Antagonists SGM ambrisentan Tier 4 SGM bosentan Tier 4 SGM macitentan Tier 4 OPSUMIT

Phosphodiesterase Inhibitors SGM sildenafil Tier 4 SGM tadalafil Tier 4

Prostacyclin Receptor Agonists SGM selexipag Tier 4 UPTRAVI

Prostaglandin Vasodilators † epoprostenol sodium FLOLAN SGM treprostinil Tier 4 SGM treprostinil ext-rel Tier 4 ORENITRAM

Soluble Guanylate Cyclase Stimulators SGM riociguat Tier 4 ADEMPAS

MISCELLANEOUS hydralazine Tier 1 methyldopa Tier 1 midodrine Tier 1 ranolazine ext-rel Tier 1

CENTRAL NERVOUS SYSTEM Practice guidelines for psychiatric disorders are available at: https://www.psychiatry.org

ANTIANXIETY Benzodiazepines alprazolam Tier 1 lorazepam Tier 1 oxazepam Tier 1 diazepam Tier 2 VALIUM clonazepam Tier 3 KLONOPIN

Miscellaneous buspirone Tier 1 fluvoxamine Tier 1 clomipramine Tier 2 ANAFRANIL

ANTICONVULSANTS Practice guidelines for the treatment of epilepsy are available at: https://www.aan.com

carbamazepine ext-rel Tier 1 clobazam Tier 1 lamotrigine Tier 1 lamotrigine ext-rel Tier 1 lamotrigine orally disintegrating tabs Tier 1 phenobarbital Tier 1 rufinamide Tier 1 tiagabine Tier 1 valproic acid Tier 1 zonisamide Tier 1 cenobamate Tier 2 XCOPRI diazepam nasal spray Tier 2 VALTOCO lacosamide Tier 2 VIMPAT midazolam nasal spray Tier 2 NAYZILAM oxcarbazepine ext-rel Tier 2 OXTELLAR XR perampanel Tier 2 FYCOMPA carbamazepine Tier 3 TEGRETOL carbamazepine ext-rel Tier 3 CARBATROL diazepam rectal gel Tier 3 DIASTAT divalproex sodium delayed-rel Tier 3 DEPAKOTE divalproex sodium ext-rel Tier 3 DEPAKOTE ER ethosuximide Tier 3 ZARONTIN gabapentin Tier 3 NEURONTIN levetiracetam Tier 3 KEPPRA levetiracetam ext-rel Tier 3 KEPPRA XR oxcarbazepine Tier 3 TRILEPTAL Tier 1 - Generics, Tier 2 – Preferred Brands, Tier 3 – Non-Preferred Brands boldface - indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name † - Coverage determined under the Medical Benefit, OTC – Over the Counter, PA – Prior Authorization, QL – Quantity Limit SGM – Specialty Guideline Management (*may require additional copay and/or PA), ST – Step Therapy

phenytoin Tier 3 DILANTIN INFATABS phenytoin sodium extended Tier 3 DILANTIN primidone Tier 3 MYSOLINE topiramate Tier 3 TOPAMAX SGM vigabatrin Tier 4

ANTIDEMENTIA Practice guidelines for the management of dementia are available at: https://www.aan.com

galantamine Tier 1 galantamine ext-rel Tier 1 memantine ext-rel Tier 1 rivastigmine Tier 1 memantine/donepezil Tier 2 NAMZARIC donepezil Tier 3 ARICEPT memantine Tier 3 NAMENDA rivastigmine transdermal Tier 3 EXELON

ANTIDEPRESSANTS Although these agents are primarily indicated for depression, some of these are also approved for other indications, including bipolar disorder, obsessive-compulsive disorder, panic disorder and premenstrual dysphoric disorder.

Guidelines for the evaluation and management of bipolar and depressive disorders are available at: https://www.psychiatry.org

Monoamine Oxidase Inhibitors (MAOIs) phenelzine Tier 2 NARDIL tranylcypromine Tier 2 PARNATE

Selective Serotonin Reuptake Inhibitors (SSRIs) escitalopram Tier 1 * fluoxetine Tier 1 paroxetine HCl Tier 1 ** paroxetine HCl ext-rel Tier 1 sertraline Tier 1 ST vortioxetine Tier 2 TRINTELLIX citalopram Tier 3 CELEXA

* Listing does not include fluoxetine tablet 60 mg, fluoxetine tablet (generics for SARAFEM).

** Listing does not include NDC 60505367503. Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package size.

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) desvenlafaxine ext-rel Tier 1 duloxetine delayed-rel Tier 1 venlafaxine Tier 1 venlafaxine ext-rel Tier 1

Tricyclic Antidepressants (TCAs) amitriptyline Tier 1 doxepin Tier 1

imipramine HCl Tier 1 desipramine Tier 2 NORPRAMIN nortriptyline Tier 2 PAMELOR

Miscellaneous Agents bupropion Tier 1 bupropion ext-rel Tier 1 trazodone Tier 1 mirtazapine Tier 3 REMERON

ANTIPARKINSONIAN AGENTS Practice guidelines for the diagnosis and treatment of Parkinson's disease are available at: https://www.aan.com

amantadine Tier 1 benztropine Tier 1 carbidopa/levodopa ext-rel Tier 1 carbidopa/levodopa orally disintegrating tabs Tier 1 pramipexole ext-rel Tier 1 rasagiline Tier 1 ropinirole Tier 1 ropinirole ext-rel Tier 1 selegiline Tier 1 trihexyphenidyl Tier 1 rotigotine transdermal Tier 2 NEUPRO bromocriptine Tier 3 PARLODEL carbidopa/levodopa Tier 3 SINEMET carbidopa/levodopa/entacapone Tier 3 STALEVO entacapone Tier 3 COMTAN pramipexole Tier 3 MIRAPEX SGM apomorphine Tier 4 KYNMOBI SGM levodopa inhalation powder Tier 4 INBRIJA

ANTIPSYCHOTICS Atypicals aripiprazole Tier 1 quetiapine ext-rel Tier 1 ziprasidone Tier 1 aripiprazole ext-rel inj Tier 2 ABILIFY MAINTENA ST cariprazine Tier 2 VRAYLAR lurasidone Tier 2 LATUDA risperidone ext-rel inj Tier 2 PERSERIS clozapine Tier 3 CLOZARIL olanzapine Tier 3 ZYPREXA paliperidone palmitate ext-rel inj Tier 3 INVEGA SUSTENNA quetiapine Tier 3 SEROQUEL risperidone Tier 3 RISPERDAL

Miscellaneous chlorpromazine Tier 1 fluphenazine Tier 1 haloperidol Tier 1 perphenazine Tier 1

prochlorperazine inj Tier 1 thiothixene Tier 1 trifluoperazine Tier 1 chlorpromazine inj Tier 3 haloperidol decanoate inj Tier 3 HALDOL DECANOATE haloperidol inj Tier 3 HALDOL

ATTENTION DEFICIT HYPERACTIVITY DISORDER Guidelines for the evaluation and management of attention deficit disorder are available at: https://www.aacap.org https://www.aap.org

QL amphetamine/dextroamphetamine mixed salts Tier 1 QL amphetamine/dextroamphetamine mixed salts ext-rel Tier 1 QL dexmethylphenidate ext-rel Tier 1 QL dextroamphetamine Tier 1 QL guanfacine ext-rel Tier 1 QL methylphenidate ext-rel Tier 1 QL amphetamine/dextroamphetamine mixed salts ext-rel Tier 2 MYDAYIS QL lisdexamfetamine Tier 2 VYVANSE QL atomoxetine Tier 3 STRATTERA QL dexmethylphenidate Tier 3 FOCALIN QL dextroamphetamine ext-rel Tier 3 DEXEDRINE SPANSULE QL methylphenidate Tier 3 METHYLIN QL methylphenidate Tier 3 RITALIN QL methylphenidate ext-rel Tier 3 CONCERTA

FIBROMYALGIA ST, QL pregabalin Tier 1

HYPNOTICS Practice parameters for the treatment of sleep disorders and clinical guidelines for the evaluation and management of chronic insomnia in adults are available at: https://aasm.org

Benzodiazepines temazepam Tier 3 RESTORIL

Nonbenzodiazepines eszopiclone Tier 1 ramelteon Tier 1 ST suvorexant Tier 2 BELSOMRA zolpidem Tier 3 AMBIEN zolpidem ext-rel Tier 3 AMBIEN CR

Tricyclics doxepin Tier 1

MIGRAINE Guidelines for prevention and management of migraine headaches are available at: https://www.aan.com

Acute Migraine Agents Ergotamine Derivatives dihydroergotamine inj Tier 2 D.H.E. 45

Triptans QL naratriptan Tier 1 QL rizatriptan Tier 1 ST sumatriptan inj Tier 2 ZEMBRACE SYMTOUCH ST sumatriptan nasal powder Tier 2 ONZETRA XSAIL QL zolmitriptan nasal spray Tier 2 ZOMIG QL eletriptan Tier 3 RELPAX QL sumatriptan Tier 3 IMITREX QL sumatriptan inj Tier 3 IMITREX QL sumatriptan nasal spray Tier 3 IMITREX QL zolmitriptan Tier 3 ZOMIG

Miscellaneous ST lasmiditan Tier 2 REYVOW ST rimegepant Tier 2 NURTEC ODT ST ubrogepant Tier 2 UBRELVY

Preventative Migraine Agents Monoclonal Antibodies ST erenumab-aooe Tier 2 AIMOVIG ST fremanezumab-vfrm Tier 2 AJOVY ST galcanezumab-gnlm Tier 2 EMGALITY

MOOD STABILIZERS lithium carbonate Tier 1 lithium carbonate ext-rel tabs 450 mg Tier 1 lithium carbonate ext-rel tabs 300 mg Tier 2 LITHOBID

MOVEMENT DISORDERS SGM deutetrabenazine Tier 4 AUSTEDO SGM tetrabenazine Tier 4 SGM valbenazine Tier 4 INGREZZA

MULTIPLE SCLEROSIS AGENTS Practice guidelines for multiple sclerosis are available at: https://www.aan.com

† natalizumab TYSABRI † ocrelizumab OCREVUS SGM dimethyl fumarate delayed-rel Tier 4 SGM diroximel fumarate delayed-rel Tier 4 VUMERITY SGM fingolimod Tier 4 GILENYA SGM glatiramer Tier 4 COPAXONE SGM interferon beta-1a Tier 4 REBIF SGM interferon beta-1b Tier 4 BETASERON SGM ofatumumab Tier 4 KESIMPTA SGM ozanimod Tier 4 ZEPOSIA SGM siponimod Tier 4 MAYZENT SGM teriflunomide Tier 4 AUBAGIO

MUSCULOSKELETAL THERAPY AGENTS baclofen Tier 1 carisoprodol 350 mg Tier 1 * chlorzoxazone 500 mg Tier 1 ** cyclobenzaprine Tier 1 *** methocarbamol Tier 1 dantrolene Tier 2 DANTRIUM metaxalone 800 mg Tier 2 SKELAXIN tizanidine tabs Tier 2 ZANAFLEX

* Listing does not include NDC 73007001303. Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package size.

** Listing does not include cyclobenzaprine tablet 7.5 mg.

*** Listing does not include NDCs 69036091010, 69036093090 and 70868090190. Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package size. MYASTHENIA GRAVIS pyridostigmine Tier 1 pyridostigmine ext-rel Tier 1

NARCOLEPSY PA armodafinil Tier 1 PA modafinil Tier 1 PA solriamfetol Tier 2 SUNOSI

POSTHERPETIC NEURALGIA (PHN) ST gabapentin ext-rel Tier 2 GRALISE

PSYCHOTHERAPEUTIC-MISCELLANEOUS Alcohol Deterrents acamprosate calcium Tier 1 disulfiram Tier 1

Opioid Antagonists naloxone inj Tier 1 naltrexone Tier 1 naloxone nasal spray Tier 2 NARCAN

Partial Opioid Agonist/Opioid Antagonist Combinations QL buprenorphine/naloxone sublingual Tier 1 QL buprenorphine/naloxone sublingual tabs Tier 2 ZUBSOLV

Pseudobulbar Affect Agents PA dextromethorphan/quinidine Tier 2 NUEDEXTA

Smoking Deterrents Treating Tobacco Use and Dependence: 2008 Update-Clinical Practice Guideline is available at: https://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html

bupropion ext-rel Tier 1

varenicline Tier 2 CHANTIX

ENDOCRINE AND METABOLIC ACROMEGALY SGM lanreotide acetate Tier 4 SOMATULINE DEPOT

ANDROGENS Clinical practice guidelines for the treatment of hypogonadism are available at: https://www.aace.com

PA testosterone cypionate Tier 1 PA testosterone enanthate Tier 1 PA, * testosterone gel Tier 1 PA testosterone soln Tier 1

PA testosterone nasal gel Tier 2 NATESTO PA testosterone transdermal Tier 2 ANDRODERM

* Listing does not include the authorized generics for TESTIM and VOGELXO.

ANTIDIABETICS Guidelines of treatment and management of diabetes are available at: https://professional.diabetes.org

Alpha-glucosidase Inhibitors acarbose Tier 2 PRECOSE

Amylin Analogs pramlintide Tier 2 SYMLINPEN

Biguanides metformin Tier 1 * metformin ext-rel Tier 1

* Listing does not include generics for FORTAMET and GLUMETZA.

Biguanide/Sulfonylurea Combinations glipizide/metformin Tier 1

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors sitagliptin phosphate Tier 2 JANUVIA

Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations sitagliptin/metformin Tier 2 JANUMET sitagliptin/metformin ext-rel Tier 2 JANUMET XR

Incretin Mimetic Agents QL dulaglutide Tier 2 TRULICITY QL liraglutide Tier 2 VICTOZA QL semaglutide Tier 2 OZEMPIC QL semaglutide Tier 2 RYBELSUS

Incretin Mimetic Agent/Insulin Combinations liraglutide/insulin degludec Tier 2 XULTOPHY lixisenatide/insulin glargine Tier 2 SOLIQUA

Insulins insulin aspart Tier 2 FIASP insulin aspart Tier 2 NOVOLOG insulin aspart protamine 70%/insulin aspart 30% Tier 2 NOVOLOG MIX 70/30 insulin degludec Tier 2 TRESIBA insulin detemir Tier 2 LEVEMIR insulin glargine Tier 2 BASAGLAR insulin glargine Tier 2 TOUJEO insulin human Tier 2 HUMULIN R U-500 OTC insulin human Tier 2 NOVOLIN R OTC insulin isophane human Tier 2 NOVOLIN N OTC insulin isophane human 70%/regular 30% Tier 2 NOVOLIN 70/30

Insulin Sensitizers pioglitazone Tier 1

Insulin Sensitizer/Biguanide Combinations pioglitazone/metformin Tier 3 ACTOPLUS MET

Insulin Sensitizer/Sulfonylurea Combinations pioglitazone/glimepiride Tier 3 DUETACT

Meglitinides nateglinide Tier 1 repaglinide Tier 1

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors dapagliflozin Tier 2 FARXIGA empagliflozin Tier 2 JARDIANCE

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitor/Biguanide Combinations dapagliflozin/metformin ext-rel Tier 2 XIGDUO XR empagliflozin/metformin Tier 2 SYNJARDY empagliflozin/metformin ext-rel Tier 2 SYNJARDY XR

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitor/Dipeptidyl Peptidase-4 (DPP-4) Inhibitor Combinations empagliflozin/linagliptin Tier 2 GLYXAMBI

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitor/Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations empagliflozin/linagliptin/metformin ext-rel Tier 2 TRIJARDY XR

Sulfonylureas glimepiride Tier 3 AMARYL glipizide Tier 3 GLUCOTROL glipizide ext-rel Tier 3 GLUCOTROL XL

Supplies PA blood glucose continuous monitoring receivers, sensors, Tier 2 DEXCOM CONTINUOUS GLUCOSE transmitters MONITORING SYSTEM OTC blood glucose monitoring kits, test strips Tier 2 ACCU-CHEK AVIVA PLUS kits and test strips OTC blood glucose monitoring kits, test strips Tier 2 ACCU-CHEK COMPACT PLUS kits and test strips OTC blood glucose monitoring kits, test strips Tier 2 ACCU-CHEK GUIDE kits and test strips OTC blood glucose monitoring kits, test strips Tier 2 ACCU-CHEK SMARTVIEW kits and test strips OTC blood glucose monitoring kits, test strips Tier 2 ONETOUCH ULTRA kits and test strips OTC blood glucose monitoring kits, test strips Tier 2 ONETOUCH VERIO kits and test strips QL insulin infusion disposable pump Tier 2 OMNIPOD DASH INSULIN INFUSION PUMP

OTC insulin syringes, needles Tier 2 BD ULTRAFINE insulin syringes and needles OTC lancets Tier 2

CALCIUM RECEPTOR ANTAGONISTS SGM cinacalcet Tier 4

CALCIUM REGULATORS Guidelines of treatment and management of osteoporosis are available at: https://www.aace.com https://www.nof.org

Bisphosphonates alendronate Tier 3 FOSAMAX ibandronate Tier 3 BONIVA risedronate Tier 3 ACTONEL risedronate delayed-rel Tier 3 ATELVIA

Calcitonins calcitonin-salmon spray Tier 1

Parathyroid Hormones SGM abaloparatide Tier 4 TYMLOS SGM teriparatide Tier 4 FORTEO

Miscellaneous † denosumab PROLIA

CARNITINE DEFICIENCY AGENTS levocarnitine Tier 1

CENTRAL PRECOCIOUS PUBERTY † histrelin acetate SUPPRELIN LA † triptorelin pamoate TRIPTODUR

CONTRACEPTIVES EE = ethinyl estradiol

Monophasic 20 mcg Estrogen drospirenone/EE 3/20 Tier 1 drospirenone/EE/levomefolate 3/20 and levomefolate Tier 1 levonorgestrel/EE 0.1/20 - Lessina Tier 1 norethindrone acetate/EE 1/20 Tier 1 norethindrone acetate/EE 1/20 and iron Tier 1 norethindrone acetate/EE 1/20 and iron chewable Tier 1

30 mcg Estrogen desogestrel/EE 0.15/30 Tier 1 drospirenone/EE 3/30 Tier 1 drospirenone/EE/levomefolate 3/30 and levomefolate Tier 1 levonorgestrel/EE 0.15/30 - Levora Tier 1 norethindrone acetate/EE 1.5/30 Tier 1

norethindrone acetate/EE 1.5/30 and iron Tier 1 norgestrel/EE 0.3/30 - Low-Ogestrel Tier 1

35 mcg Estrogen ethynodiol diacetate/EE 1/35 - Zovia 1/35 Tier 1 norethindrone/EE 0.5/35 Tier 1 norethindrone/EE 1/35 Tier 1 norgestimate/EE 0.25/35 Tier 1

50 mcg Estrogen ethynodiol diacetate/EE 1/50 Tier 1

Biphasic desogestrel/EE Tier 2 MIRCETTE

Triphasic desogestrel/EE Tier 1 levonorgestrel/EE - Trivora Tier 1 norethindrone/EE Tier 1 norgestimate/EE Tier 1

Extended Cycle levonorgestrel/EE 0.15/30 Tier 1 levonorgestrel/EE 0.15/30 and EE 10 Tier 1 levonorgestrel/EE 0.1/20 and EE 10 Tier 3 LOSEASONIQUE

Progestin Only norethindrone Tier 1 norethindrone Tier 2 ORTHO MICRONOR

Injectable medroxyprogesterone acetate 150 mg/mL Tier 2 DEPO-PROVERA

Progestin Intrauterine Devices † levonorgestrel releasing IUD KYLEENA † levonorgestrel releasing IUD MIRENA † levonorgestrel releasing IUD SKYLA

Transdermal norelgestromin/EE Tier 1

Vaginal etonogestrel/EE ring Tier 1 segesterone acetate/EE ring Tier 2 ANNOVERA

ENDOMETRIOSIS danazol Tier 1 PA elagolix Tier 2 ORILISSA

FERTILITY REGULATORS GNRH/LHRH Antagonists cetrorelix Tier 4 CETROTIDE ganirelix acetate Tier 4

Ovulation Stimulants, Gonadotropins choriogonadotropin alfa Tier 4 OVIDREL PA follitropin alfa Tier 4 GONAL-F

Ovulation Stimulants, Synthetic clomiphene Tier 1

GAUCHER DISEASE † imiglucerase CEREZYME SGM eliglustat Tier 4 CERDELGA

GLUCOCORTICOIDS dexamethasone Tier 1 fludrocortisone Tier 1 prednisolone Tier 1 prednisone Tier 1 hydrocortisone Tier 3 CORTEF methylprednisolone Tier 3 MEDROL

GLUCOSE ELEVATING AGENTS glucagon nasal powder Tier 2 BAQSIMI glucagon subcutaneous soln Tier 2 GVOKE glucagon, human recombinant Tier 2 GLUCAGEN HYPOKIT glucagon, human recombinant Tier 2 GLUCAGON EMERGENCY KIT

HEREDITARY TYROSINEMIA TYPE 1 AGENTS SGM nitisinone Tier 4 ORFADIN

HUMAN GROWTH HORMONES Guidelines for use of growth hormone are available at: https://www.aace.com/publications/guidelines

SGM somatropin Tier 4 GENOTROPIN SGM somatropin Tier 4 NORDITROPIN

HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol (1,25-D3) Tier 2 ROCALTROL doxercalciferol Tier 2 HECTOROL paricalcitol Tier 2 ZEMPLAR

MENOPAUSAL SYMPTOM AGENTS Guidelines of treatment and management of hormone therapy and menopause are available at: https://www.menopause.org https://www.aace.com/files/menopause.pdf

Oral EE/norethindrone acetate - Jinteli Tier 1 estradiol/norethindrone Tier 1 estrogens, conjugated/bazedoxifene Tier 2 DUAVEE estrogens, conjugated/medroxyprogesterone Tier 2 PREMPHASE estrogens, conjugated/medroxyprogesterone Tier 2 PREMPRO estradiol Tier 3 ESTRACE

Transdermal estradiol Tier 1 estradiol Tier 2 DIVIGEL estradiol Tier 2 EVAMIST estradiol/levonorgestrel Tier 2 CLIMARA PRO estradiol/norethindrone acetate Tier 2 COMBIPATCH estradiol Tier 3 CLIMARA

Vaginal estradiol vaginal crm Tier 1 estradiol vaginal inserts Tier 2 IMVEXXY estradiol vaginal tabs Tier 3 VAGIFEM

PHENYLKETONURIA TREATMENT AGENTS SGM sapropterin Tier 4

PHOSPHATE BINDER AGENTS calcium acetate Tier 1 sevelamer carbonate Tier 1 calcium acetate Tier 2 PHOSLYRA ST sucroferric oxyhydroxide Tier 2 VELPHORO

POLYNEUROPATHY SGM inotersen Tier 4 TEGSEDI

POTASSIUM-REMOVING AGENTS patiromer sorbitex Tier 2 VELTASSA sodium zirconium cyclosilicate Tier 2 LOKELMA

PROGESTINS Oral megestrol acetate susp Tier 1 progesterone, micronized Tier 1 medroxyprogesterone acetate Tier 3 PROVERA norethindrone acetate Tier 3 AYGESTIN

Vaginal PA progesterone gel Tier 2 CRINONE PA progesterone vaginal inserts Tier 2 ENDOMETRIN

SELECTIVE ESTROGEN RECEPTOR MODULATORS raloxifene Tier 3 EVISTA

THYROID AGENTS Antithyroid Agents propylthiouracil Tier 1 methimazole Tier 2 TAPAZOLE

Thyroid Supplements levothyroxine Tier 1 levothyroxine - Levoxyl Tier 1 liothyronine Tier 1

levothyroxine Tier 2 SYNTHROID

UTERINE FIBROIDS PA elagolix sodium/estradiol/norethindrone acetate Tier 2 ORIAHNN

VASOPRESSINS desmopressin spray, tabs Tier 2 DDAVP

MISCELLANEOUS cabergoline Tier 1

GASTROINTESTINAL Guidelines for the treatment and management of various gastrointestinal diseases/conditions are available at: https://gi.org https://www.gastro.org

ANTIDIARRHEALS loperamide Tier 1 diphenoxylate/atropine Tier 2 LOMOTIL

ANTIEMETICS QL aprepitant Tier 1 QL granisetron Tier 1 meclizine Tier 1 prochlorperazine Tier 1 promethazine Tier 1 scopolamine transdermal Tier 1 PA, QL granisetron transdermal Tier 2 SANCUSO PA, QL dronabinol Tier 3 MARINOL metoclopramide Tier 3 REGLAN QL ondansetron Tier 3 ZOFRAN trimethobenzamide Tier 3 TIGAN

ANTISPASMODICS dicyclomine Tier 1 hyoscyamine sulfate orally disintegrating tabs Tier 1 hyoscyamine sulfate Tier 2 LEVSIN

CHOLELITHOLYTICS ursodiol Tier 1 ursodiol Tier 2 URSO H2 RECEPTOR ANTAGONISTS cimetidine Tier 1 famotidine Tier 3 PEPCID

INFLAMMATORY BOWEL DISEASE Oral Agents balsalazide Tier 1 budesonide delayed-rel caps Tier 1 budesonide ext-rel Tier 1 mesalamine delayed-rel caps Tier 1 * mesalamine delayed-rel tabs Tier 1 mesalamine ext-rel caps Tier 1 Tier 1 - Generics, Tier 2 – Preferred Brands, Tier 3 – Non-Preferred Brands boldface - indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name † - Coverage determined under the Medical Benefit, OTC – Over the Counter, PA – Prior Authorization, QL – Quantity Limit SGM – Specialty Guideline Management (*may require additional copay and/or PA), ST – Step Therapy

mesalamine ext-rel caps Tier 2 PENTASA sulfasalazine Tier 3 AZULFIDINE sulfasalazine delayed-rel Tier 3 AZULFIDINE EN-TABS

* Listing does not include mesalamine delayed-rel tablet 800 mg.

Rectal Agents hydrocortisone enema Tier 1 mesalamine supp Tier 1 hydrocortisone acetate foam Tier 2 CORTIFOAM mesalamine susp Tier 3 ROWASA

IRRITABLE BOWEL SYNDROME Irritable Bowel Syndrome with Constipation lubiprostone Tier 1 linaclotide Tier 2 LINZESS

Irritable Bowel Syndrome with Diarrhea alosetron Tier 1 eluxadoline Tier 2 VIBERZI

LAXATIVES lactulose soln Tier 1 peg 3350/electrolytes Tier 1 sodium picosulfate/magnesium oxide/citric acid Tier 2 CLENPIQ peg 3350/electrolytes Tier 3 NULYTELY

OPIOID-INDUCED CONSTIPATION naldemedine Tier 2 SYMPROIC naloxegol Tier 2 MOVANTIK

PANCREATIC ENZYMES pancrelipase Tier 2 VIOKACE pancrelipase delayed-rel Tier 2 CREON pancrelipase delayed-rel Tier 2 ZENPEP

PROSTAGLANDINS misoprostol Tier 2 CYTOTEC

PROTON PUMP INHIBITORS esomeprazole delayed-rel Tier 1 lansoprazole delayed-rel Tier 1 omeprazole delayed-rel Tier 1 pantoprazole delayed-rel tabs Tier 1 ST dexlansoprazole delayed-rel Tier 2 DEXILANT

SALIVA STIMULANTS cevimeline Tier 2 EVOXAC pilocarpine tabs Tier 2 SALAGEN

STEROIDS, RECTAL hydrocortisone acetate/pramoxine foam Tier 2 PROCTOFOAM-HC hydrocortisone crm Tier 2 ANUSOL-HC

ULCER THERAPY COMBINATIONS lansoprazole + amoxicillin + clarithromycin Tier 1

MISCELLANEOUS sucralfate tablet Tier 1

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA Guidelines for the management of BPH are available at: https://www.auanet.org/guidelines

alfuzosin ext-rel Tier 1 dutasteride/tamsulosin Tier 1 silodosin Tier 1 dutasteride Tier 3 AVODART finasteride Tier 3 PROSCAR tamsulosin Tier 3 FLOMAX

URINARY ANTISPASMODICS darifenacin ext-rel Tier 1 oxybutynin Tier 1 solifenacin Tier 1 tolterodine ext-rel Tier 1 trospium Tier 1 trospium ext-rel Tier 1 ST fesoterodine ext-rel Tier 2 TOVIAZ ST mirabegron ext-rel Tier 2 MYRBETRIQ oxybutynin ext-rel Tier 3 DITROPAN XL tolterodine Tier 3 DETROL

VAGINAL ANTI-INFECTIVES metronidazole Tier 1 terconazole Tier 1 clindamycin crm Tier 2 CLEOCIN

MISCELLANEOUS bethanechol Tier 1 potassium citrate ext-rel Tier 2 UROCIT-K

HEMATOLOGIC Guidelines of treatment and management of hemophilia are available at: https://www.hemophilia.org

ANTICOAGULANTS CHEST guidelines are available at: https://www.chestnet.org/Guidelines-and-Resources/CHEST-Guideline-Topic-Areas/Pulmonary-Vascular

Injectable enoxaparin Tier 1 dalteparin Tier 2 FRAGMIN

Oral warfarin Tier 1 apixaban Tier 2 ELIQUIS rivaroxaban Tier 2 XARELTO

Synthetic Heparinoid-like Agents fondaparinux Tier 2 ARIXTRA

CHELATING AGENTS ST penicillamine capsule Tier 1 ST trientine Tier 1 SGM deferasirox Tier 4 SGM deferiprone Tier 4 † deferoxamine

HEMATOPOIETIC GROWTH FACTORS Guidelines for the management of neutropenia are available at: https://www.asco.org

Guidelines for the management of anemia associated with chronic kidney disease are available at: https://www.kidney.org/professionals/guidelines#guidelines

SGM darbepoetin alfa Tier 4 ARANESP SGM epoetin alfa-epbx Tier 4 RETACRIT SGM filgrastim-aafi Tier 4 NIVESTYM SGM pegfilgrastim-bmez Tier 4 ZIEXTENZO

HEMOPHILIA A AGENTS † antihemophilic factor (recombinant) ADVATE † antihemophilic factor (recombinant) KOGENATE FS † antihemophilic factor (recombinant) KOVALTRY † antihemophilic factor (recombinant) NOVOEIGHT † antihemophilic factor (recombinant) Fc fusion protein ELOCTATE † antihemophilic factor (recombinant) pegylated ADYNOVATE † antihemophilic factor (recombinant) pegylated-aucl JIVI † antihemophilic factor (recombinant) single chain AFSTYLA † antihemophilic factor (recombinant), glycopegylated-exei ESPEROCT † human coagulation factor VIII (rDNA) simoctocog alfa NUWIQ

HEMOPHILIA B AGENTS † coagulation factor IX (recombinant) glycopegylated REBINYN

PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS † eculizumab SOLIRIS

PLATELET AGGREGATION INHIBITORS clopidogrel Tier 1 dipyridamole Tier 1 dipyridamole ext-rel/aspirin Tier 1 prasugrel Tier 1 ticagrelor Tier 2 BRILINTA

PLATELET SYNTHESIS INHIBITORS anagrelide Tier 2 AGRYLIN

STEM CELL MOBILIZERS SGM plerixafor Tier 4 MOZOBIL

THROMBOCYTOPENIA AGENTS SGM avatrombopag Tier 4 DOPTELET SGM lusutrombopag Tier 4 MULPLETA

MISCELLANEOUS cilostazol Tier 1

IMMUNOLOGIC AGENTS Guidelines for the management of rheumatic diseases are available at: https://www.rheumatology.org

ALLERGENIC EXTRACTS PA ragweed pollen allergen extract Tier 2 RAGWITEK PA timothy grass pollen allergen extract Tier 2 GRASTEK PA grass mixed pollen allergen extract Tier 4 ORALAIR

AUTOIMMUNE AGENTS (PHYSICIAN-ADMINISTERED) † golimumab SIMPONI ARIA † infliximab REMICADE † ustekinumab STELARA INTRAVENOUS

AUTOIMMUNE AGENTS (SELF-ADMINISTERED) ‡ ‡ Coverage may be altered or copay amounts may vary based on the condition being treated (e.g., psoriasis)

SGM adalimumab Tier 4 HUMIRA SGM apremilast Tier 4 OTEZLA SGM etanercept Tier 4 ENBREL SGM guselkumab Tier 4 TREMFYA SGM risankizumab-rzaa Tier 4 SKYRIZI SGM secukinumab Tier 4 COSENTYX SGM tofacitinib Tier 4 XELJANZ SGM tofacitinib ext-rel Tier 4 XELJANZ XR SGM upadacitinib Tier 4 RINVOQ SGM ustekinumab Tier 4 STELARA SUBCUTANEOUS

DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) methotrexate Tier 1 hydroxychloroquine Tier 2 PLAQUENIL leflunomide Tier 2 ARAVA SGM methotrexate auto-injector Tier 4 RASUVO

HEREDITARY ANGIOEDEMA SGM icatibant Tier 4

IMMUNOMODULATORS CDC recommendations on the treatment of hepatitis are available at: https://www.cdc.gov/hepatitis/Resources/ Tier 1 - Generics, Tier 2 – Preferred Brands, Tier 3 – Non-Preferred Brands boldface - indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name † - Coverage determined under the Medical Benefit, OTC – Over the Counter, PA – Prior Authorization, QL – Quantity Limit SGM – Specialty Guideline Management (*may require additional copay and/or PA), ST – Step Therapy

Guidelines for the management of hepatitis are available at: https://www.aasld.org

Immune Globulins SGM immune globulin (human)-hipp Tier 4 CUTAQUIG

Interferons SGM interferon alfa-2b Tier 4 INTRON A SGM peginterferon alfa-2a Tier 4 PEGASYS

Miscellaneous SGM canakinumab Tier 4 ILARIS

IMMUNOSUPPRESSANTS Antimetabolites mycophenolate mofetil Tier 1 mycophenolate sodium delayed-rel Tier 1 azathioprine Tier 2 AZASAN azathioprine Tier 2 IMURAN

Calcineurin Inhibitors cyclosporine Tier 1 cyclosporine, modified Tier 1 tacrolimus Tier 1

Rapamycin Derivatives sirolimus Tier 1

NUTRITIONAL/SUPPLEMENTS ELECTROLYTES Potassium potassium chloride ext-rel Tier 1 potassium chloride liquid Tier 1

VITAMINS AND MINERALS Folic Acid/Combinations folic acid Tier 1 folic acid/vitamin B6/vitamin B12 Tier 1

Prenatal Vitamins prenatal vitamins Tier 1 prenatal vitamins/DHA/docusate/folic acid Tier 2 CITRANATAL 90 DHA prenatal vitamins/DHA/docusate/folic acid Tier 2 CITRANATAL DHA prenatal vitamins/DHA/docusate/folic acid Tier 2 CITRANATAL HARMONY prenatal vitamins/docusate/folic acid Tier 2 CITRANATAL RX prenatal vitamins/docusate/folic acid + DHA Tier 2 CITRANATAL ASSURE prenatal vitamins/folic acid + pyridoxine Tier 2 CITRANATAL B-CALM

Miscellaneous cyanocobalamin inj Tier 1 fluoride drops Tier 1 fluoride tabs Tier 1 Tier 1 - Generics, Tier 2 – Preferred Brands, Tier 3 – Non-Preferred Brands boldface - indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name † - Coverage determined under the Medical Benefit, OTC – Over the Counter, PA – Prior Authorization, QL – Quantity Limit SGM – Specialty Guideline Management (*may require additional copay and/or PA), ST – Step Therapy

multivitamins/fluoride drops, tabs Tier 1 multivitamins/fluoride/iron drops, tabs Tier 1 vitamin ADC/fluoride drops Tier 1 vitamin ADC/fluoride/iron drops Tier 1

RESPIRATORY Guidelines to the management, prevention, or treatment of COPD and asthma are available at: https://www.aaaai.org https://ginasthma.org https://goldcopd.org https://www.nhlbi.nih.gov

The Allergy Report and guidelines for allergy-related conditions are available at: https://www.aaaai.org

ALPHA-1 ANTITRYPSIN DEFICIENCY AGENTS † alpha-1 proteinase inhibitor PROLASTIN-C

ANAPHYLAXIS TREATMENT AGENTS epinephrine auto-injector Tier 1 epinephrine Tier 2 SYMJEPI epinephrine auto-injector Tier 2 EPIPEN epinephrine auto-injector Tier 2 EPIPEN JR.

ANTICHOLINERGICS QL ipratropium soln Tier 1 QL revefenacin inhalation soln Tier 2 YUPELRI QL tiotropium Tier 2 SPIRIVA

ANTICHOLINERGIC/BETA AGONIST COMBINATIONS Short Acting QL ipratropium/albuterol soln Tier 1

Long Acting QL tiotropium/olodaterol Tier 2 STIOLTO RESPIMAT QL umeclidinium/vilanterol Tier 2 ANORO ELLIPTA

ANTICHOLINERGIC/BETA AGONIST/STEROID INHALANT COMBINATIONS QL budesonide/glycopyrrolate/formoterol Tier 2 BREZTRI AEROSPHERE QL fluticasone/umeclidinium/vilanterol Tier 2 TRELEGY ELLIPTA

ANTIHISTAMINES, LOW SEDATING levocetirizine Tier 1

ANTIHISTAMINES, SEDATING clemastine 2.68 mg Tier 1 cyproheptadine Tier 1 hydroxyzine HCl Tier 1

ANTITUSSIVES Clinical practice guidelines are available at: https://journal.chestnet.org/article/S0012-3692(15)52856-0/pdf

* benzonatate Tier 2 TESSALON

* Listing does not include NDC 69336012615 and 69499032915. Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package size.

ANTITUSSIVE COMBINATIONS Opioid codeine/promethazine Tier 1 codeine/promethazine/phenylephrine Tier 1 hydrocodone/homatropine Tier 1

Non-opioid dextromethorphan/brompheniramine/pseudoephedrine Tier 1 dextromethorphan/promethazine Tier 1

BETA AGONISTS Inhalants Short Acting QL albuterol soln Tier 1 QL albuterol sulfate CFC-free aerosol Tier 1 QL levalbuterol tartrate, CFC-free aerosol Tier 1

Long Acting Hand-held Active Inhalation QL olodaterol, CFC-free aerosol Tier 2 STRIVERDI RESPIMAT QL salmeterol xinafoate Tier 2 SEREVENT

Nebulized Passive Inhalation QL formoterol inhalation soln Tier 2 PERFOROMIST

Oral Agents albuterol Tier 1 albuterol ext-rel Tier 1 terbutaline Tier 1

CYSTIC FIBROSIS SGM dornase alfa Tier 4 PULMOZYME SGM tobramycin inhalation soln Tier 4 SGM tobramycin inhalation soln Tier 4 BETHKIS

LEUKOTRIENE MODULATORS montelukast Tier 1 zafirlukast Tier 1

MAST CELL STABILIZERS QL cromolyn soln Tier 1

NASAL ANTIHISTAMINES QL azelastine spray Tier 1 ST, QL, * olopatadine spray Tier 3 PATANASE

* Step Therapy applies to brand only

NASAL STEROIDS/COMBINATIONS QL azelastine/fluticasone spray Tier 1 QL flunisolide spray Tier 1 QL fluticasone spray Tier 1 QL mometasone spray Tier 1

PHOSPHODIESTERASE-4 INHIBITORS roflumilast Tier 2 DALIRESP

PULMONARY FIBROSIS AGENTS SGM nintedanib Tier 4 OFEV SGM pirfenidone Tier 4 ESBRIET

SEVERE ASTHMA AGENTS † omalizumab XOLAIR SGM benralizumab Tier 4 FASENRA autoinjector SGM dupilumab Tier 4 DUPIXENT SGM mepolizumab Tier 4 NUCALA autoinjector

STEROID/BETA AGONIST COMBINATIONS QL budesonide/formoterol Tier 2 SYMBICORT QL fluticasone/salmeterol Tier 2 ADVAIR DISKUS QL, ^ fluticasone/salmeterol, CFC-free aerosol Tier 2 ADVAIR HFA QL, ^ fluticasone/vilanterol Tier 2 BREO ELLIPTA

^ Listing does not include certain NDCs. Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package size.

STEROID INHALANTS QL beclomethasone breath-activated aerosol Tier 2 QVAR REDIHALER QL budesonide Tier 2 PULMICORT FLEXHALER QL fluticasone Tier 2 ARNUITY ELLIPTA QL fluticasone Tier 2 FLOVENT DISKUS QL fluticasone, CFC-free aerosol Tier 2 FLOVENT HFA QL budesonide inhalation susp Tier 3 PULMICORT RESPULES

XANTHINES theophylline ext-rel tabs Tier 1

MISCELLANEOUS ipratropium spray Tier 1

TOPICAL DERMATOLOGY Acne Guidelines for the care and treatment of acne vulgaris are available at: https://www.aad.org/practicecenter/quality/clinical-guidelines

Oral PA isotretinoin Tier 1

Topical PA adapalene Tier 1 Tier 1 - Generics, Tier 2 – Preferred Brands, Tier 3 – Non-Preferred Brands boldface - indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name † - Coverage determined under the Medical Benefit, OTC – Over the Counter, PA – Prior Authorization, QL – Quantity Limit SGM – Specialty Guideline Management (*may require additional copay and/or PA), ST – Step Therapy

QL, ^ clindamycin gel Tier 1 clindamycin/benzoyl peroxide Tier 1 QL erythromycin gel 2% Tier 1 erythromycin soln Tier 1 PA tazarotene Tier 1 PA, * tretinoin Tier 1 PA, * tretinoin - Avita Tier 1 PA, * tretinoin gel microsphere Tier 1 adapalene/benzoyl peroxide Tier 2 EPIDUO adapalene/benzoyl peroxide Tier 2 EPIDUO FORTE clindamycin/benzoyl peroxide Tier 2 ONEXTON benzoyl peroxide Tier 3 BENZAC AC clindamycin gel, lotion Tier 3 CLEOCIN T QL clindamycin soln Tier 3 CLEOCIN T erythromycin/benzoyl peroxide Tier 3 BENZAMYCIN sulfacetamide lotion 10% Tier 3 KLARON PA, * tretinoin Tier 3 RETIN-A

* Prior Authorization applies for members age 35 and older

^ Listing does not include NDC 68682046275. Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package size.

Actinic Keratosis fluorouracil crm 5%, soln 5%, soln 2% Tier 1 fluorouracil crm 4% Tier 2 TOLAK imiquimod Tier 2 ZYCLARA ingenol mebutate Tier 2 PICATO

Antibiotics QL gentamicin Tier 1 QL mupirocin oint Tier 1 silver sulfadiazine Tier 2 SILVADENE

Antifungals clotrimazole Tier 1 QL econazole Tier 1 QL ketoconazole crm 2% Tier 1 QL nystatin Tier 1 naftifine Tier 2 NAFTIN PA ciclopirox Tier 3 LOPROX

Antipsoriatics Guidelines of care for the management and treatment of psoriasis with topical therapies are available at: https://www.aad.org

Oral PA acitretin Tier 3 SORIATANE methoxsalen oral Tier 3 OXSORALEN-ULTRA

Topical QL calcipotriene oint, soln 0.005% Tier 1

Antiseborrheics ketoconazole shampoo 2% Tier 1 selenium sulfide lotion 2.5% Tier 1

Atopic Dermatitis Guidelines for the treatment of atopic dermatitis are available at: https://www.aad.org/practicecenter/quality/clinical-guidelines

Injectable SGM dupilumab Tier 4 DUPIXENT

Topical PA pimecrolimus Tier 1 PA tacrolimus Tier 1 ST crisaborole Tier 2 EUCRISA

Corticosteroids Low Potency QL alclometasone crm, oint 0.05% Tier 1 QL fluocinolone acetonide soln 0.01% Tier 1 QL hydrocortisone crm 2.5% Tier 1 QL hydrocortisone lotion 1% Tier 1 PA, QL, * desonide crm, lotion, oint 0.05% Tier 2 DESOWEN

* Prior Authorization applies to brand only

Medium Potency QL betamethasone valerate crm, lotion, oint 0.1% Tier 1 QL desoximetasone crm 0.05% Tier 1 QL fluocinolone acetonide crm, oint 0.025% Tier 1 QL fluticasone propionate crm, lotion 0.05%, oint 0.005% Tier 1 QL hydrocortisone butyrate crm, oint, soln 0.1% Tier 1 QL hydrocortisone valerate crm, oint 0.2% Tier 1 QL mometasone crm, lotion, oint 0.1% Tier 1 QL triamcinolone acetonide crm, lotion 0.025% Tier 1 QL triamcinolone acetonide crm, lotion, oint 0.1% Tier 1

High Potency QL betamethasone dipropionate augmented lotion 0.05% Tier 1 QL betamethasone dipropionate crm, lotion, oint 0.05% Tier 1 QL desoximetasone crm, oint 0.25%, gel 0.05% Tier 1 QL fluocinonide crm, gel, oint, soln 0.05% Tier 1 QL triamcinolone acetonide crm 0.5% Tier 1 PA halobetasol propionate lotion 0.01% Tier 2 BRYHALI PA, QL, * betamethasone dipropionate augmented crm 0.05% Tier 3 DIPROLENE AF

* Prior Authorization applies to brand only

Very High Potency QL clobetasol propionate foam 0.05% Tier 1 QL halobetasol propionate crm, oint 0.05% Tier 1 PA, QL, * betamethasone dipropionate augmented gel, oint 0.05% Tier 2 DIPROLENE PA, QL, * clobetasol propionate crm, gel, oint 0.05% Tier 2 TEMOVATE

PA, QL, * clobetasol propionate lotion, shampoo 0.05% Tier 2 CLOBEX PA, QL, * clobetasol propionate soln 0.05% Tier 3 TEMOVATE

* Prior Authorization applies to brand only

Emollients ammonium lactate 12% Tier 1

Local Analgesics PA lidocaine patch Tier 2 LIDODERM

Rosacea PA azelaic acid gel Tier 1 metronidazole gel 0.75% Tier 1 PA azelaic acid foam Tier 2 FINACEA FOAM PA doxycycline monohydrate delayed-rel caps Tier 2 ORACEA PA ivermectin Tier 2 SOOLANTRA metronidazole crm 0.75% Tier 3 METROCREAM metronidazole gel 1% Tier 3 METROGEL metronidazole lotion 0.75% Tier 3 METROLOTION

Scabicides and Pediculicides permethrin 5% Tier 1 malathion Tier 2 OVIDE

Miscellaneous Skin and Mucous Membrane imiquimod Tier 1 podofilox Tier 2 CONDYLOX

MOUTH/THROAT/DENTAL AGENTS Anesthetics - Topical Oral lidocaine viscous Tier 1

Steroids - Mouth/Throat triamcinolone paste Tier 1

OPHTHALMIC Preferred Practice Pattern Guidelines for the treatment of various ophthalmic conditions are available at: https://one.aao.org

Antiallergics azelastine Tier 1 cromolyn sodium Tier 1 olopatadine Tier 1

Anti-infectives bacitracin Tier 1 ciprofloxacin Tier 1 erythromycin Tier 1 QL gentamicin Tier 1 levofloxacin Tier 1 moxifloxacin Tier 1 neomycin/polymyxin B/gramicidin Tier 1

polymyxin B/bacitracin Tier 1 sulfacetamide oint 10% Tier 1 besifloxacin Tier 2 BESIVANCE moxifloxacin Tier 3 VIGAMOX ofloxacin Tier 3 OCUFLOX polymyxin B/trimethoprim Tier 3 POLYTRIM sulfacetamide soln 10% Tier 3 BLEPH-10 tobramycin Tier 3 TOBREX

Anti-infective/Anti-inflammatory Combinations neomycin/polymyxin B/bacitracin/hydrocortisone oint Tier 1 neomycin/polymyxin B/hydrocortisone susp Tier 1 sulfacetamide/prednisolone phosphate 10%/0.25% Tier 1 tobramycin/dexamethasone oint 0.3%/0.1% Tier 2 TOBRADEX neomycin/polymyxin B/dexamethasone Tier 3 MAXITROL tobramycin/dexamethasone susp 0.3%/0.1% Tier 3 TOBRADEX

Anti-inflammatories Nonsteroidal bromfenac sodium Tier 1 diclofenac sodium Tier 1 bromfenac sodium Tier 2 PROLENSA nepafenac Tier 2 ILEVRO QL ketorolac Tier 3 ACULAR

Steroidal dexamethasone sodium phosphate Tier 1 fluorometholone Tier 1 loteprednol Tier 1 prednisolone acetate 1% Tier 1 difluprednate Tier 2 DUREZOL prednisolone phosphate 1% Tier 3

Antivirals trifluridine Tier 1

Beta-blockers Nonselective levobunolol Tier 1 timolol maleate gel Tier 1 timolol maleate soln Tier 1

Selective betaxolol Tier 2 BETOPTIC S

Carbonic Anhydrase Inhibitors Topical brinzolamide Tier 1 dorzolamide Tier 3 TRUSOPT

Carbonic Anhydrase Inhibitor/Beta-blocker Combinations dorzolamide/timolol maleate Tier 3 COSOPT

Carbonic Anhydrase Inhibitor/Sympathomimetic Combinations brinzolamide/brimonidine Tier 2 SIMBRINZA

Dry Eye Disease cyclosporine, emulsion Tier 2 RESTASIS lifitegrast Tier 2 XIIDRA

Prostaglandins travoprost Tier 1 ST bimatoprost 0.01% Tier 2 LUMIGAN ST tafluprost Tier 2 ZIOPTAN latanoprost Tier 3 XALATAN

Retinal Disorders † aflibercept EYLEA † ranibizumab LUCENTIS

Rho Kinase Inhibitors netarsudil Tier 2 RHOPRESSA

Rho Kinase Inhibitor/Prostaglandin Combinations ST netarsudil/latanoprost Tier 2 ROCKLATAN

Sympathomimetics brimonidine 0.2% Tier 1 brimonidine Tier 2 ALPHAGAN P

Sympathomimetic/Beta-blocker Combinations brimonidine/timolol Tier 2 COMBIGAN

OTIC Clinical practice guidelines for the treatment of otitis media are available at: https://www.aap.org

Anti-infectives acetic acid Tier 1 ofloxacin otic Tier 1

Anti-infective/Anti-inflammatory Combinations ciprofloxacin/dexamethasone Tier 1 neomycin/polymyxin B/hydrocortisone Tier 1

WEBSITES Agency for Healthcare Research and Quality American Congress of Obstetricians and https://www.ahrq.gov Gynecologists https://www.acog.org Alzheimer's Association https://www.alz.org American Diabetes Association http://www.diabetes.org American Academy of Allergy, Asthma and Immunology American Gastroenterological Association https://www.aaaai.org https://www.gastro.org

American Academy of Child & Adolescent Psychiatry American Headache Society Committee for Headache https://www.aacap.org Education https://americanheadachesociety.org American Academy of Dermatology https://www.aad.org American Heart Association https://professional.heart.org American Academy of Neurology https://www.aan.com American Lung Association https://www.lung.org American Academy of Ophthalmology https://www.aao.org American Medical Association https://www.ama-assn.org American Academy of Pediatrics https://www.aap.org American Psychiatric Association https://www.psychiatry.org American Association for the Study of Liver Disease https://www.aasld.org American Society of Anesthesiologists https://www.asahq.org American Association of Clinical Endocrinologists https://www.aace.com American Society of Clinical Oncology https://www.asco.org American Association of Diabetes Educators https://www.diabeteseducator.org American Society of Interventional Pain Physicians https://www.asipp.org American Cancer Society https://www.cancer.org American Urological Association https://www.auanet.org American College of Allergy, Asthma and Immunology https://www.acaai.org Centers for Disease Control and Prevention https://www.cdc.gov American College of Cardiology https://www.acc.org Centers for Disease Control and Prevention Guideline topics: AIDS American College of Chest Physicians https://www.cdc.gov/hiv/default.html https://www.chestnet.org Centers for Disease Control and Prevention American College of Gastroenterology Guideline topics: Sexually Transmitted Diseases https://gi.org https://www.cdc.gov/std/treatment/default.htm

American College of Physicians CVS Caremark https://www.acponline.org https://www.caremark.com

American College of Rheumatology The Food and Drug Administration https://www.rheumatology.org https://www.fda.gov

Global Initiative for Asthma National Foundation for Infectious Diseases https://ginasthma.org http://www.nfid.org

Infectious Diseases Society of America National Guideline Clearinghouse https://www.idsociety.org https://www.ahrq.gov

Institute for Safe Medication Practices National Heart, Lung and Blood Institute https://www.ismp.org https://www.nhlbi.nih.gov

Johns Hopkins AIDS Service National Institutes of Health https://www.thebody.com/content/art12096.html https://www.nih.gov

Juvenile Diabetes Research Foundation International National Kidney Foundation https://www.jdrf.org https://www.kidney.org

MedWatch National Osteoporosis Foundation https://www.fda.gov/Safety/MedWatch/default.htm https://www.nof.org

National Agricultural Library North American Menopause Society https://www.nal.usda.gov https://www.menopause.org

National Cancer Institute United States Department of Health and Human https://www.cancer.gov/about-cancer Services https://www.hhs.gov National Comprehensive Cancer Network https://www.nccn.org World Health Organization https://www.who.int

INDEX

A AMBIEN, 22 AMBIEN CR, 22 abacavir, 10 ambrisentan, 18 abacavir/dolutegravir/lamivudine, 9 amiloride, 18 abacavir/lamivudine, 10 amiloride/hydrochlorothiazide, 17 abaloparatide, 28 amiodarone, 15 ABILIFY MAINTENA, 21 amitriptyline, 20 abiraterone, 12 amlodipine, 17 acalabrutinib, 12 amlodipine/atorvastatin, 17 acamprosate calcium, 24 amlodipine/benazepril, 14 acarbose, 26 amlodipine/olmesartan, 15 ACCU-CHEK AVIVA PLUS kits and test strips, 27 amlodipine/telmisartan, 15 ACCU-CHEK COMPACT PLUS kits and test strips, 27 amlodipine/valsartan, 15 ACCU-CHEK GUIDE kits and test strips, 27 amlodipine/valsartan/hydrochlorothiazide, 15 ACCU-CHEK SMARTVIEW kits and test strips, 27 ammonium lactate 12%, 43 ACCUPRIL, 14 amoxicillin, 9 ACCURETIC, 14 amoxicillin/clavulanate, 9 acetazolamide, 17 amoxicillin/clavulanate ext-rel, 9 acetazolamide ext-rel, 17 amphetamine/dextroamphetamine mixed salts, 22 acetic acid, 45 amphetamine/dextroamphetamine mixed salts ext-rel, 22 acitretin, 41 ampicillin, 9 ACTONEL, 28 ANAFRANIL, 19 ACTOPLUS MET, 27 anagrelide, 36 ACULAR, 44 anastrozole, 12 acyclovir caps, tabs, 11 ANDRODERM, 26 adalimumab, 36 ANNOVERA, 29 adapalene, 40 ANORO ELLIPTA, 38 adapalene/benzoyl peroxide, 41 antihemophilic factor (recombinant), 35 ADEMPAS, 18 antihemophilic factor (recombinant) Fc fusion protein, 35 ADVAIR DISKUS, 40 antihemophilic factor (recombinant) pegylated, 35 ADVAIR HFA, 40 antihemophilic factor (recombinant) pegylated-aucl, 35 ADVATE, 35 antihemophilic factor (recombinant) single chain, 35 ADYNOVATE, 35 antihemophilic factor (recombinant), glycopegylated-exei, 35 AFINITOR, 12 ANUSOL-HC, 33 aflibercept, 45 apalutamide, 12 AFSTYLA, 35 apixaban, 35 AGRYLIN, 36 apomorphine, 21 AIMOVIG, 23 apremilast, 36 AJOVY, 23 aprepitant, 32 albuterol, 39 ARANESP, 35 albuterol ext-rel, 39 ARAVA, 36 albuterol soln, 39 ARICEPT, 20 albuterol sulfate CFC-free aerosol, 39 ARIMIDEX, 12 alclometasone crm, oint 0.05%, 42 aripiprazole, 21 ALDACTAZIDE, 17 aripiprazole ext-rel inj, 21 ALDACTONE, 14 ARIXTRA, 35 ALECENSA, 12 armodafinil, 24 alectinib, 12 ARNUITY ELLIPTA, 40 alendronate, 28 AROMASIN, 12 alfuzosin ext-rel, 34 atazanavir, 10 alirocumab, 16 atazanavir/cobicistat, 10 aliskiren, 17 ATELVIA, 28 aliskiren/hydrochlorothiazide, 17 atenolol, 16 ALKERAN, 12 atenolol/chlorthalidone, 17 allopurinol, 7 atomoxetine, 22 alosetron, 33 atorvastatin, 16 alpha-1 proteinase inhibitor, 38 atovaquone/proguanil, 9 ALPHAGAN P, 45 AUBAGIO, 23 alprazolam, 19 AUGMENTIN, 9 ALTACE, 14 AUSTEDO, 23 ALUNBRIG, 12 avatrombopag, 36 amantadine, 21 AVODART, 34 AMARYL, 27 AYGESTIN, 31

AZASAN, 37 brimonidine, 45 azathioprine, 37 brimonidine 0.2%, 45 azelaic acid foam, 43 brimonidine/timolol, 45 azelaic acid gel, 43 brinzolamide, 44 azelastine, 43 brinzolamide/brimonidine, 45 azelastine spray, 39 bromfenac sodium, 44 azelastine/fluticasone spray, 40 bromocriptine, 21 azithromycin, 9 BRYHALI, 42 AZULFIDINE, 33 budesonide, 40 AZULFIDINE EN-TABS, 33 budesonide delayed-rel caps, 32 B budesonide ext-rel, 32 budesonide inhalation susp, 40 bacitracin, 43 budesonide/formoterol, 40 baclofen, 24 budesonide/glycopyrrolate/formoterol, 38 balsalazide, 32 bumetanide, 17 BAQSIMI, 30 buprenorphine, 8 BARACLUDE, 11 buprenorphine transdermal, 7 BASAGLAR, 26 buprenorphine/naloxone sublingual, 24 BD ULTRAFINE insulin syringes and needles, 28 buprenorphine/naloxone sublingual tabs, 24 beclomethasone breath-activated aerosol, 40 bupropion, 21 BELBUCA, 8 bupropion ext-rel, 21, 24 BELSOMRA, 22 buspirone, 19 bempedoic acid, 15 busulfan, 12 bempedoic acid/ezetimibe, 15 BYSTOLIC, 16 benazepril, 14 benazepril/hydrochlorothiazide, 14 C benralizumab, 40 cabergoline, 32 BENZAC AC, 41 CABOMETYX, 12 BENZAMYCIN, 41 cabozantinib, 12 benzonatate, 39 CADUET, 17 benzoyl peroxide, 41 CALAN SR, 17 benztropine, 21 calcipotriene oint, soln 0.005%, 41 besifloxacin, 44 calcitonin-salmon spray, 28 BESIVANCE, 44 calcitriol (1,25-D3), 30 betamethasone dipropionate augmented crm 0.05%, 42 calcium acetate, 31 betamethasone dipropionate augmented gel, oint 0.05%, 42 CALQUENCE, 12 betamethasone dipropionate augmented lotion 0.05%, 42 canakinumab, 37 betamethasone dipropionate crm, lotion, oint 0.05%, 42 candesartan, 15 betamethasone valerate crm, lotion, oint 0.1%, 42 candesartan/hydrochlorothiazide, 15 BETASERON, 23 capecitabine, 12 betaxolol, 44 captopril, 14 bethanechol, 34 captopril/hydrochlorothiazide, 14 BETHKIS, 39 carbamazepine, 19 BETOPTIC S, 44 carbamazepine ext-rel, 19 bevacizumab-bvzr, 12 CARBATROL, 19 bexarotene caps, 13 carbidopa/levodopa, 21 bicalutamide, 12 carbidopa/levodopa ext-rel, 21 bictegravir/emtricitabine/tenofovir alafenamide, 10 carbidopa/levodopa orally disintegrating tabs, 21 BIDIL, 18 carbidopa/levodopa/entacapone, 21 BIKTARVY, 10 CARDURA, 14 bimatoprost 0.01%, 45 cariprazine, 21 bisoprolol, 16 carisoprodol 350 mg, 24 bisoprolol/hydrochlorothiazide, 17 carvedilol, 16 BLEPH-10, 44 carvedilol phosphate ext-rel, 16 blood glucose continuous monitoring receivers, sensors, transmitters, CASODEX, 12 27 CATAPRES-TTS, 14 blood glucose monitoring kits, test strips, 27 cefadroxil, 8 BONIVA, 28 cefdinir, 9 bortezomib, 13 cefixime, 9 bosentan, 18 cefprozil, 8 BOSULIF, 12 cefuroxime axetil, 8 bosutinib, 12 celecoxib, 7 BREO ELLIPTA, 40 CELEXA, 20 BREZTRI AEROSPHERE, 38 cenobamate, 19 brigatinib, 12 cephalexin, 8 BRILINTA, 35 CERDELGA, 30

CEREZYME, 30 COMBIGAN, 45 cetrorelix, 29 COMBIPATCH, 31 CETROTIDE, 29 COMPLERA, 10 cevimeline, 33 COMTAN, 21 CHANTIX, 25 CONCERTA, 22 chlorambucil, 12 CONDYLOX, 43 chloroquine, 9 COPAXONE, 23 chlorpromazine, 21 COPIKTRA, 12 chlorpromazine inj, 22 COREG, 16 chlorthalidone, 18 CORGARD, 16 chlorzoxazone 500 mg, 24 CORLANOR, 18 cholestyramine, 16 CORTEF, 30 choriogonadotropin alfa, 30 CORTIFOAM, 33 ciclopirox, 41 COSENTYX, 36 cilostazol, 36 COSOPT, 44 CIMDUO, 10 CREON, 33 cimetidine, 32 CRINONE, 31 cinacalcet, 28 crisaborole, 42 CIPRO, 9 cromolyn sodium, 43 ciprofloxacin, 9, 43 cromolyn soln, 39 ciprofloxacin/dexamethasone, 45 CUTAQUIG, 37 citalopram, 20 cyanocobalamin inj, 37 CITRANATAL 90 DHA, 37 cyclobenzaprine, 24 CITRANATAL ASSURE, 37 cyclophosphamide caps, 12 CITRANATAL B-CALM, 37 cyclosporine, 37 CITRANATAL DHA, 37 cyclosporine, emulsion, 45 CITRANATAL HARMONY, 37 cyclosporine, modified, 37 CITRANATAL RX, 37 cyproheptadine, 38 clarithromycin, 9 CYTOTEC, 33 clarithromycin ext-rel, 9 D clemastine 2.68 mg, 38 D.H.E. 45, 23 CLENPIQ, 33 DALIRESP, 40 CLEOCIN, 11, 34 dalteparin, 34 CLEOCIN T, 41 danazol, 29 CLIMARA, 31 DANTRIUM, 24 CLIMARA PRO, 31 dantrolene, 24 clindamycin, 11 dapagliflozin, 27 clindamycin crm, 34 dapagliflozin/metformin ext-rel, 27 clindamycin gel, 41 dapsone, 11 clindamycin gel, lotion, 41 darbepoetin alfa, 35 clindamycin soln, 41 darifenacin ext-rel, 34 clindamycin/benzoyl peroxide, 41 darolutamide, 12 clobazam, 19 darunavir, 10 clobetasol propionate crm, gel, oint 0.05%, 42 darunavir/cobicistat, 10 clobetasol propionate foam 0.05%, 42 darunavir/cobicistat/emtricitabine/tenofovir alafenamide, 10 clobetasol propionate lotion, shampoo 0.05%, 43 dasatinib, 12 clobetasol propionate soln 0.05%, 43 DDAVP, 32 CLOBEX, 43 deferasirox, 35 clomiphene, 30 deferiprone, 35 clomipramine, 19 deferoxamine, 35 clonazepam, 19 degarelix acetate, 13 clonidine, 14 denosumab, 28 clonidine transdermal, 14 DEPAKOTE, 19 clopidogrel, 35 DEPAKOTE ER, 19 clotrimazole, 41 DEPO-PROVERA, 29 clotrimazole troches, 9 DESCOVY, 10 clozapine, 21 desipramine, 21 CLOZARIL, 21 desmopressin spray, tabs, 32 coagulation factor IX (recombinant) glycopegylated, 35 desogestrel/EE, 29 codeine/acetaminophen, 7 desogestrel/EE 0.15/30, 28 codeine/promethazine, 39 desonide crm, lotion, oint 0.05%, 42 codeine/promethazine/phenylephrine, 39 DESOWEN, 42 colchicine tabs, 7 desoximetasone crm 0.05%, 42 colesevelam, 15 desoximetasone crm, oint 0.25%, gel 0.05%, 42 COLESTID, 16 desvenlafaxine ext-rel, 20 colestipol, 16

DETROL, 34 dronabinol, 32 deutetrabenazine, 23 dronedarone, 15 dexamethasone, 30 drospirenone/EE 3/20, 28 dexamethasone sodium phosphate, 44 drospirenone/EE 3/30, 28 DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM, 27 drospirenone/EE/levomefolate 3/20 and levomefolate, 28 DEXEDRINE SPANSULE, 22 drospirenone/EE/levomefolate 3/30 and levomefolate, 28 DEXILANT, 33 DUAVEE, 30 dexlansoprazole delayed-rel, 33 DUETACT, 27 dexmethylphenidate, 22 dulaglutide, 26 dexmethylphenidate ext-rel, 22 duloxetine delayed-rel, 20 dextroamphetamine, 22 dupilumab, 40, 42 dextroamphetamine ext-rel, 22 DUPIXENT, 40, 42 dextromethorphan/brompheniramine/pseudoephedrine, 39 DUREZOL, 44 dextromethorphan/promethazine, 39 dutasteride, 34 dextromethorphan/quinidine, 24 dutasteride/tamsulosin, 34 DIASTAT, 19 duvelisib, 12 diazepam, 19 E diazepam nasal spray, 19 econazole, 41 diazepam rectal gel, 19 eculizumab, 35 diclofenac sodium, 44 EDURANT, 10 diclofenac sodium delayed-rel, 7 EE/norethindrone acetate - Jinteli, 30 diclofenac sodium delayed-rel/misoprostol, 7 efavirenz, 10 diclofenac sodium gel 1%, 7 efavirenz/emtricitabine/tenofovir disoproxil fumarate, 9 diclofenac sodium soln, 7 efavirenz/lamivudine/tenofovir disoproxil fumarate, 9 dicloxacillin, 9 elagolix, 29 dicyclomine, 32 elagolix sodium/estradiol/norethindrone acetate, 32 DIFICID, 9 eletriptan, 23 DIFLUCAN, 9 ELIGARD, 13 diflunisal, 7 eliglustat, 30 difluprednate, 44 ELIQUIS, 35 digoxin 0.0625 mg, 0.1875 mg, 17 ELOCTATE, 35 digoxin 0.125 mg, 0.25 mg, 17 eluxadoline, 33 digoxin ped elixir, 17 elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide, 10 dihydroergotamine inj, 23 elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate, 10 DILANTIN, 20 EMGALITY, 23 DILANTIN INFATABS, 20 empagliflozin, 27 diltiazem ext-rel, 17 empagliflozin/linagliptin, 27 dimethyl fumarate delayed-rel, 23 empagliflozin/linagliptin/metformin ext-rel, 27 diphenoxylate/atropine, 32 empagliflozin/metformin, 27 DIPROLENE, 42 empagliflozin/metformin ext-rel, 27 DIPROLENE AF, 42 emtricitabine, 10 dipyridamole, 35 emtricitabine/rilpivirine/tenofovir alafenamide, 10 dipyridamole ext-rel/aspirin, 35 emtricitabine/rilpivirine/tenofovir disoproxil fumarate, 10 diroximel fumarate delayed-rel, 23 emtricitabine/tenofovir alafenamide, 10 disopyramide, 15 emtricitabine/tenofovir disoproxil fumarate, 9 disopyramide ext-rel, 15 EMTRIVA, 10 disulfiram, 24 EMVERM, 11 DITROPAN XL, 34 enalapril, 14 divalproex sodium delayed-rel, 19 enalapril/hydrochlorothiazide, 14 divalproex sodium ext-rel, 19 ENBREL, 36 DIVIGEL, 31 ENDOMETRIN, 31 dofetilide, 15 enfuvirtide, 10 dolutegravir, 10 enoxaparin, 34 dolutegravir/lamivudine, 10 entacapone, 21 donepezil, 20 entecavir soln, 11 DOPTELET, 36 entecavir tabs, 11 dornase alfa, 39 ENTRESTO, 18 dorzolamide, 44 enzalutamide, 12 dorzolamide/timolol maleate, 44 EPCLUSA, 11 DOVATO, 10 EPIDUO, 41 doxazosin, 14 EPIDUO FORTE, 41 doxepin, 20, 22 epinephrine, 38 doxercalciferol, 30 epinephrine auto-injector, 38 doxycycline hyclate, 9 EPIPEN, 38 doxycycline hyclate 20 mg, 9 EPIPEN JR., 38 doxycycline monohydrate delayed-rel caps, 43

51 eplerenone, 14 FINACEA FOAM, 43 epoetin alfa-epbx, 35 finasteride, 34 epoprostenol sodium, 18 fingolimod, 23 EPZICOM, 10 FIRMAGON, 13 erenumab-aooe, 23 FLAGYL, 11 ERIVEDGE, 13 flecainide, 15 ERLEADA, 12 FLOLAN, 18 erlotinib, 12 FLOMAX, 34 erythromycin, 43 FLOVENT DISKUS, 40 erythromycin delayed-rel, 9 FLOVENT HFA, 40 erythromycin ethylsuccinate, 9 fluconazole, 9 erythromycin gel 2%, 41 fludrocortisone, 30 erythromycin soln, 41 flunisolide spray, 40 erythromycin stearate, 9 fluocinolone acetonide crm, oint 0.025%, 42 erythromycin/benzoyl peroxide, 41 fluocinolone acetonide soln 0.01%, 42 ESBRIET, 40 fluocinonide crm, gel, oint, soln 0.05%, 42 escitalopram, 20 fluoride drops, 37 esomeprazole delayed-rel, 33 fluoride tabs, 37 ESPEROCT, 35 fluorometholone, 44 ESTRACE, 30 fluorouracil crm 4%, 41 estradiol, 30, 31 fluorouracil crm 5%, soln 5%, soln 2%, 41 estradiol vaginal crm, 31 fluoxetine, 20 estradiol vaginal inserts, 31 fluphenazine, 21 estradiol vaginal tabs, 31 flutamide, 12 estradiol/levonorgestrel, 31 fluticasone, 40 estradiol/norethindrone, 30 fluticasone propionate crm, lotion 0.05%, oint 0.005%, 42 estradiol/norethindrone acetate, 31 fluticasone spray, 40 estrogens, conjugated/bazedoxifene, 30 fluticasone, CFC-free aerosol, 40 estrogens, conjugated/medroxyprogesterone, 30 fluticasone/salmeterol, 40 eszopiclone, 22 fluticasone/salmeterol, CFC-free aerosol, 40 etanercept, 36 fluticasone/umeclidinium/vilanterol, 38 ethambutol, 10 fluticasone/vilanterol, 40 ethosuximide, 19 fluvastatin, 16 ethynodiol diacetate/EE 1/35 - Zovia 1/35, 29 fluvoxamine, 19 ethynodiol diacetate/EE 1/50, 29 FOCALIN, 22 etonogestrel/EE ring, 29 folic acid, 37 etoposide, 13 folic acid/vitamin B6/vitamin B12, 37 etravirine, 10 follitropin alfa, 30 EUCRISA, 42 fondaparinux, 35 EVAMIST, 31 formoterol inhalation soln, 39 everolimus, 12 FORTEO, 28 EVISTA, 31 FOSAMAX, 28 EVOTAZ, 10 fosinopril, 14 EVOXAC, 33 fosinopril/hydrochlorothiazide, 14 EXELON, 20 FRAGMIN, 34 exemestane, 12 fremanezumab-vfrm, 23 EYLEA, 45 furosemide, 17 ezetimibe, 16 FUZEON, 10 ezetimibe/simvastatin, 16 FYCOMPA, 19 F G famciclovir, 11 gabapentin, 19 famotidine, 32 gabapentin ext-rel, 24 FARXIGA, 27 galantamine, 20 FASENRA autoinjector, 40 galantamine ext-rel, 20 felodipine ext-rel, 17 galcanezumab-gnlm, 23 FEMARA, 12 ganirelix acetate, 29 fenofibrate, 16 gefitinib, 12 fenofibric acid delayed-rel, 16 gemfibrozil, 16 fentanyl sublingual spray, 8 GENOTROPIN, 30 fentanyl transdermal, 7 gentamicin, 41, 43 fentanyl transmucosal lozenge, 7 GENVOYA, 10 fesoterodine ext-rel, 34 GILENYA, 23 FIASP, 26 gilteritinib, 13 fidaxomicin, 9 glatiramer, 23 filgrastim-aafi, 35 glimepiride, 27

52 glipizide, 27 icosapent ethyl, 16 glipizide ext-rel, 27 ILARIS, 37 glipizide/metformin, 26 ILEVRO, 44 GLUCAGEN HYPOKIT, 30 imatinib mesylate, 13 GLUCAGON EMERGENCY KIT, 30 imiglucerase, 30 glucagon nasal powder, 30 imipramine HCl, 21 glucagon subcutaneous soln, 30 imiquimod, 41, 43 glucagon, human recombinant, 30 IMITREX, 23 GLUCOTROL, 27 immune globulin (human)-hipp, 37 GLUCOTROL XL, 27 IMURAN, 37 GLYXAMBI, 27 IMVEXXY, 31 golimumab, 36 INBRIJA, 21 GONAL-F, 30 indapamide, 18 GRALISE, 24 infliximab, 36 granisetron, 32 ingenol mebutate, 41 granisetron transdermal, 32 INGREZZA, 23 grass mixed pollen allergen extract, 36 inotersen, 31 GRASTEK, 36 INSPRA, 14 griseofulvin ultramicrosize, 9 insulin aspart, 26 guanfacine, 14 insulin aspart protamine 70%/insulin aspart 30%, 26 guanfacine ext-rel, 22 insulin degludec, 26 guselkumab, 36 insulin detemir, 26 GVOKE, 30 insulin glargine, 26 H insulin human, 26 insulin infusion disposable pump, 27 HALDOL, 22 insulin isophane human, 26 HALDOL DECANOATE, 22 insulin isophane human 70%/regular 30%, 26 halobetasol propionate crm, oint 0.05%, 42 insulin syringes, needles, 28 halobetasol propionate lotion 0.01%, 42 INTELENCE, 10 haloperidol, 21 interferon alfa-2b, 37 haloperidol decanoate inj, 22 interferon beta-1a, 23 haloperidol inj, 22 interferon beta-1b, 23 HARVONI, 11 INTRON A, 37 HECTOROL, 30 INVEGA SUSTENNA, 21 histrelin acetate, 28 ipratropium soln, 38 human coagulation factor VIII (rDNA) simoctocog alfa, 35 ipratropium spray, 40 HUMIRA, 36 ipratropium/albuterol soln, 38 HUMULIN R U-500, 26 irbesartan, 15 HYCAMTIN, 13 irbesartan/hydrochlorothiazide, 15 hydralazine, 19 IRESSA, 12 HYDREA, 13 ISENTRESS, 10 hydrochlorothiazide, 18 isoniazid, 10 hydrocodone ext-rel, 7 isosorbide dinitrate, 18 hydrocodone/acetaminophen, 7 isosorbide dinitrate/hydralazine, 18 hydrocodone/homatropine, 39 isosorbide mononitrate, 18 hydrocortisone, 30 isosorbide mononitrate ext-rel, 18 hydrocortisone acetate foam, 33 isotretinoin, 40 hydrocortisone acetate/pramoxine foam, 33 itraconazole, 9 hydrocortisone butyrate crm, oint, soln 0.1%, 42 ivabradine, 18 hydrocortisone crm, 33 ivermectin, 11, 43 hydrocortisone crm 2.5%, 42 ixazomib, 13 hydrocortisone enema, 33 hydrocortisone lotion 1%, 42 J hydrocortisone valerate crm, oint 0.2%, 42 JANUMET, 26 hydromorphone, 7 JANUMET XR, 26 hydromorphone ext-rel, 7 JANUVIA, 26 hydroxychloroquine, 36 JARDIANCE, 27 hydroxyurea, 13 JIVI, 35 hydroxyzine HCl, 38 K hyoscyamine sulfate, 32 KANJINTI, 12 hyoscyamine sulfate orally disintegrating tabs, 32 KEFLEX, 8 I KEPPRA, 19 ibandronate, 28 KEPPRA XR, 19 IBRANCE, 13 KESIMPTA, 23 ibuprofen, 7 ketoconazole crm 2%, 41 icatibant, 36 ketoconazole shampoo 2%, 42

53 ketorolac, 44 lisdexamfetamine, 22 KISQALI, 13 lisinopril, 14 KISQALI FEMARA CO-PACK, 13 lisinopril/hydrochlorothiazide, 14 KLARON, 41 lithium carbonate, 23 KLONOPIN, 19 lithium carbonate ext-rel tabs 300 mg, 23 KOGENATE FS, 35 lithium carbonate ext-rel tabs 450 mg, 23 KOSELUGO, 13 LITHOBID, 23 KOVALTRY, 35 lixisenatide/insulin glargine, 26 KYLEENA, 29 LOKELMA, 31 KYNMOBI, 21 LOMOTIL, 32 L LONSURF, 12 loperamide, 32 labetalol, 16 LOPID, 16 lacosamide, 19 lopinavir/ritonavir, 10 lactulose soln, 33 LOPROX, 41 lamivudine, 10, 11 lorazepam, 19 lamivudine/tenofovir disoproxil fumarate, 10 losartan, 15 lamivudine/zidovudine, 9 losartan/hydrochlorothiazide, 15 lamotrigine, 19 LOSEASONIQUE, 29 lamotrigine ext-rel, 19 LOTENSIN, 14 lamotrigine orally disintegrating tabs, 19 LOTENSIN HCT, 14 lancets, 28 loteprednol, 44 LANOXIN, 17 LOTREL, 14 lanreotide acetate, 25 lovastatin, 16 lansoprazole + amoxicillin + clarithromycin, 34 LOVAZA, 16 lansoprazole delayed-rel, 33 lubiprostone, 33 lapatinib, 13 LUCENTIS, 45 LASIX, 17 LUMIGAN, 45 lasmiditan, 23 lurasidone, 21 latanoprost, 45 lusutrombopag, 36 LATUDA, 21 LYNPARZA, 13 ledipasvir/sofosbuvir, 11 LYSODREN, 13 leflunomide, 36 lenalidomide, 13 M letrozole, 12 macitentan, 18 LEUKERAN, 12 MACROBID, 11 leuprolide acetate, 13 MALARONE, 9 levalbuterol tartrate, CFC-free aerosol, 39 malathion, 43 LEVEMIR, 26 MARINOL, 32 levetiracetam, 19 MATULANE, 13 levetiracetam ext-rel, 19 MAXITROL, 44 levobunolol, 44 MAXZIDE, 17 levocarnitine, 28 MAYZENT, 23 levocetirizine, 38 mebendazole chewable, 11 levodopa inhalation powder, 21 meclizine, 32 levofloxacin, 9, 43 MEDROL, 30 levonorgestrel releasing IUD, 29 medroxyprogesterone acetate, 31 levonorgestrel/EE - Trivora, 29 medroxyprogesterone acetate 150 mg/mL, 29 levonorgestrel/EE 0.1/20 - Lessina, 28 mefloquine, 9 levonorgestrel/EE 0.1/20 and EE 10, 29 megestrol acetate susp, 31 levonorgestrel/EE 0.15/30, 29 megestrol acetate tabs, 12 levonorgestrel/EE 0.15/30 - Levora, 28 meloxicam tablet, 7 levonorgestrel/EE 0.15/30 and EE 10, 29 melphalan, 12 levothyroxine, 31, 32 memantine, 20 levothyroxine - Levoxyl, 31 memantine ext-rel, 20 LEVSIN, 32 memantine/donepezil, 20 lidocaine patch, 43 mepolizumab, 40 lidocaine viscous, 43 mercaptopurine, 12 LIDODERM, 43 mesalamine delayed-rel caps, 32 lifitegrast, 45 mesalamine delayed-rel tabs, 32 linaclotide, 33 mesalamine ext-rel caps, 32, 33 linezolid, 11 mesalamine supp, 33 LINZESS, 33 mesalamine susp, 33 liothyronine, 31 metaxalone 800 mg, 24 liraglutide, 26 metformin, 26 liraglutide/insulin degludec, 26 metformin ext-rel, 26

54 methadone, 7 naloxone inj, 24 methazolamide, 17 naloxone nasal spray, 24 methimazole, 31 naltrexone, 24 methocarbamol, 24 NAMENDA, 20 methotrexate, 12, 36 NAMZARIC, 20 methotrexate auto-injector, 36 naproxen sodium tabs, 7 methoxsalen oral, 41 naproxen tabs, 7 methyldopa, 19 naratriptan, 23 METHYLIN, 22 NARCAN, 24 methylphenidate, 22 NARDIL, 20 methylphenidate ext-rel, 22 natalizumab, 23 methylprednisolone, 30 nateglinide, 27 metoclopramide, 32 NATESTO, 26 metolazone, 18 NAYZILAM, 19 metoprolol succinate ext-rel, 16 nebivolol, 16 metoprolol tartrate, 16 neomycin/polymyxin B/bacitracin/hydrocortisone oint, 44 metoprolol/hydrochlorothiazide, 17 neomycin/polymyxin B/dexamethasone, 44 METROCREAM, 43 neomycin/polymyxin B/gramicidin, 43 METROGEL, 43 neomycin/polymyxin B/hydrocortisone, 45 METROLOTION, 43 neomycin/polymyxin B/hydrocortisone susp, 44 metronidazole, 11, 34 nepafenac, 44 metronidazole crm 0.75%, 43 netarsudil, 45 metronidazole gel 0.75%, 43 netarsudil/latanoprost, 45 metronidazole gel 1%, 43 NEUPRO, 21 metronidazole lotion 0.75%, 43 NEURONTIN, 19 midazolam nasal spray, 19 nevirapine, 10 midodrine, 19 nevirapine ext-rel, 10 midostaurin, 13 NEXLETOL, 15 minocycline, 9 NEXLIZET, 15 mirabegron ext-rel, 34 niacin ext-rel, 16 MIRAPEX, 21 NIASPAN, 16 MIRCETTE, 29 nifedipine ext-rel, 17 MIRENA, 29 NINLARO, 13 mirtazapine, 21 nintedanib, 40 misoprostol, 33 niraparib, 13 mitotane, 13 nitisinone, 30 modafinil, 24 NITRO-DUR, 18 mometasone crm, lotion, oint 0.1%, 42 nitrofurantoin ext-rel, 11 mometasone spray, 40 nitrofurantoin macrocrystals, 11 montelukast, 39 nitrofurantoin susp, 11 morphine, 7 nitroglycerin lingual spray, 18 morphine ext-rel, 7 nitroglycerin sublingual, 18 morphine supp, 7 nitroglycerin transdermal, 18 MOVANTIK, 33 NITROLINGUAL, 18 moxifloxacin, 9, 43, 44 NITROSTAT, 18 MOZOBIL, 36 NIVESTYM, 35 MULPLETA, 36 NORDITROPIN, 30 MULTAQ, 15 norelgestromin/EE, 29 multivitamins/fluoride drops, tabs, 38 norethindrone, 29 multivitamins/fluoride/iron drops, tabs, 38 norethindrone acetate, 31 mupirocin oint, 41 norethindrone acetate/EE 1.5/30, 28 MYAMBUTOL, 10 norethindrone acetate/EE 1.5/30 and iron, 29 mycophenolate mofetil, 37 norethindrone acetate/EE 1/20, 28 mycophenolate sodium delayed-rel, 37 norethindrone acetate/EE 1/20 and iron, 28 MYDAYIS, 22 norethindrone acetate/EE 1/20 and iron chewable, 28 MYLERAN, 12 norethindrone/EE, 29 MYRBETRIQ, 34 norethindrone/EE 0.5/35, 29 MYSOLINE, 20 norethindrone/EE 1/35, 29 N norgestimate/EE, 29 norgestimate/EE 0.25/35, 29 nabumetone, 7 norgestrel/EE 0.3/30 - Low-Ogestrel, 29 nadolol, 16 NORPACE CR, 15 naftifine, 41 NORPRAMIN, 21 NAFTIN, 41 nortriptyline, 21 naldemedine, 33 NORVIR, 10 naloxegol, 33 NOVOEIGHT, 35

NOVOLIN 70/30, 26 oxycodone soln 5 mg/5 mL, 7 NOVOLIN N, 26 oxycodone tabs 5 mg, 15 mg, 30 mg, 8 NOVOLIN R, 26 oxycodone/acetaminophen 5/325, 8 NOVOLOG, 26 ozanimod, 23 NOVOLOG MIX 70/30, 26 OZEMPIC, 26 NUBEQA, 12 P NUCALA autoinjector, 40 palbociclib, 13 NUCYNTA, 8 paliperidone palmitate ext-rel inj, 21 NUCYNTA ER, 8 PAMELOR, 21 NUEDEXTA, 24 pancrelipase, 33 NULYTELY, 33 pancrelipase delayed-rel, 33 NURTEC ODT, 23 pantoprazole delayed-rel tabs, 33 NUWIQ, 35 paricalcitol, 30 nystatin, 9, 41 PARLODEL, 21 O PARNATE, 20 ocrelizumab, 23 paroxetine HCl, 20 OCREVUS, 23 paroxetine HCl ext-rel, 20 OCUFLOX, 44 PATANASE, 39 ODEFSEY, 10 patiromer sorbitex, 31 ODOMZO, 13 pazopanib, 13 ofatumumab, 23 peg 3350/electrolytes, 33 OFEV, 40 PEGASYS, 37 ofloxacin, 44 pegfilgrastim-bmez, 35 ofloxacin otic, 45 peginterferon alfa-2a, 37 olanzapine, 21 penicillamine capsule, 35 olaparib, 13 penicillin VK, 9 olmesartan, 15 PENTASA, 33 olmesartan/amlodipine/hydrochlorothiazide, 15 PEPCID, 32 olmesartan/hydrochlorothiazide, 15 perampanel, 19 olodaterol, CFC-free aerosol, 39 PERFOROMIST, 39 olopatadine, 43 perindopril, 14 olopatadine spray, 39 PERJETA, 13 omalizumab, 40 permethrin 5%, 43 omega-3 acid ethyl esters, 16 perphenazine, 21 omeprazole delayed-rel, 33 PERSERIS, 21 OMNIPOD DASH INSULIN INFUSION PUMP, 27 pertuzumab, 13 ondansetron, 32 pertuzumab/trastuzumab/hyaluronidase-zzxf, 13 ONETOUCH ULTRA kits and test strips, 27 phenelzine, 20 ONETOUCH VERIO kits and test strips, 27 phenobarbital, 19 ONEXTON, 41 phenytoin, 20 ONZETRA XSAIL, 23 phenytoin sodium extended, 20 OPSUMIT, 18 PHESGO, 13 ORACEA, 43 PHOSLYRA, 31 ORALAIR, 36 PICATO, 41 ORENITRAM, 18 pilocarpine tabs, 33 ORFADIN, 30 pimecrolimus, 42 ORIAHNN, 32 pindolol, 16 ORILISSA, 29 pioglitazone, 27 ORTHO MICRONOR, 29 pioglitazone/glimepiride, 27 oseltamivir, 11 pioglitazone/metformin, 27 osimertinib, 13 pirfenidone, 40 OTEZLA, 36 PLAQUENIL, 36 OVIDE, 43 plerixafor, 36 OVIDREL, 30 podofilox, 43 oxaprozin, 7 polymyxin B/bacitracin, 44 oxazepam, 19 polymyxin B/trimethoprim, 44 oxcarbazepine, 19 POLYTRIM, 44 oxcarbazepine ext-rel, 19 pomalidomide, 13 OXSORALEN-ULTRA, 41 POMALYST, 13 OXTELLAR XR, 19 potassium chloride ext-rel, 37 oxybutynin, 34 potassium chloride liquid, 37 oxybutynin ext-rel, 34 potassium citrate ext-rel, 34 oxycodone caps 5 mg, 7 PRALUENT, 16 oxycodone concentrate 20 mg/mL, 7 pramipexole, 21 oxycodone ext-rel, 8 pramipexole ext-rel, 21

56 pramlintide, 26 REBINYN, 35 prasugrel, 35 REGLAN, 32 pravastatin, 16 regorafenib, 13 PRECOSE, 26 RELENZA, 11 prednisolone, 30 RELPAX, 23 prednisolone acetate 1%, 44 REMERON, 21 prednisolone phosphate 1%, 44 REMICADE, 36 prednisone, 30 repaglinide, 27 pregabalin, 22 RESTASIS, 45 PREMPHASE, 30 RESTORIL, 22 PREMPRO, 30 RETACRIT, 35 prenatal vitamins, 37 RETIN-A, 41 prenatal vitamins/DHA/docusate/folic acid, 37 RETROVIR, 10 prenatal vitamins/docusate/folic acid, 37 revefenacin inhalation soln, 38 prenatal vitamins/docusate/folic acid + DHA, 37 REVLIMID, 13 prenatal vitamins/folic acid + pyridoxine, 37 REYVOW, 23 PREZCOBIX, 10 RHOPRESSA, 45 PREZISTA, 10 ribavirin, 11 primidone, 20 ribociclib, 13 probenecid, 7 ribociclib + letrozole, 13 procarbazine, 13 RIFADIN, 10 PROCARDIA XL, 17 rifampin, 10 prochlorperazine, 32 rifaximin 550 mg, 11 prochlorperazine inj, 22 rilpivirine, 10 PROCTOFOAM-HC, 33 rimegepant, 23 progesterone gel, 31 RINVOQ, 36 progesterone vaginal inserts, 31 riociguat, 18 progesterone, micronized, 31 risankizumab-rzaa, 36 PROLASTIN-C, 38 risedronate, 28 PROLENSA, 44 risedronate delayed-rel, 28 PROLIA, 28 RISPERDAL, 21 promethazine, 32 risperidone, 21 propafenone, 15 risperidone ext-rel inj, 21 propafenone ext-rel, 15 RITALIN, 22 propranolol, 16 ritonavir, 10 propranolol ext-rel, 16 rituximab-pvvr, 12 propylthiouracil, 31 rivaroxaban, 35 PROSCAR, 34 rivastigmine, 20 PROVERA, 31 rivastigmine transdermal, 20 PULMICORT FLEXHALER, 40 rizatriptan, 23 PULMICORT RESPULES, 40 ROCALTROL, 30 PULMOZYME, 39 ROCKLATAN, 45 pyrazinamide, 10 roflumilast, 40 pyridostigmine, 24 ropinirole, 21 pyridostigmine ext-rel, 24 ropinirole ext-rel, 21 pyrimethamine, 11 rosuvastatin, 16 Q rotigotine transdermal, 21 ROWASA, 33 QUESTRAN/QUESTRAN LIGHT, 16 RUBRACA, 13 quetiapine, 21 rucaparib, 13 quetiapine ext-rel, 21 rufinamide, 19 quinapril, 14 RUXIENCE, 12 quinapril/hydrochlorothiazide, 14 RYBELSUS, 26 QVAR REDIHALER, 40 RYDAPT, 13 R RYTHMOL SR, 15 ragweed pollen allergen extract, 36 S RAGWITEK, 36 sacubitril/valsartan, 18 raloxifene, 31 SALAGEN, 33 raltegravir, 10 salmeterol xinafoate, 39 ramelteon, 22 SANCUSO, 32 ramipril, 14 sapropterin, 31 ranibizumab, 45 scopolamine transdermal, 32 ranolazine ext-rel, 19 secukinumab, 36 rasagiline, 21 segesterone acetate/EE ring, 29 RASUVO, 36 selegiline, 21 REBIF, 23

57 selenium sulfide lotion 2.5%, 42 sumatriptan nasal powder, 23 selexipag, 18 sumatriptan nasal spray, 23 selumetinib, 13 sunitinib, 13 semaglutide, 26 SUNOSI, 24 SEREVENT, 39 SUPPRELIN LA, 28 SEROQUEL, 21 SUPRAX, 9 sertraline, 20 SUTENT, 13 sevelamer carbonate, 31 suvorexant, 22 sildenafil, 18 SYMBICORT, 40 silodosin, 34 SYMJEPI, 38 SILVADENE, 41 SYMLINPEN, 26 silver sulfadiazine, 41 SYMPROIC, 33 SIMBRINZA, 45 SYMTUZA, 10 SIMPONI ARIA, 36 SYNJARDY, 27 simvastatin, 16 SYNJARDY XR, 27 SINEMET, 21 SYNTHROID, 32 siponimod, 23 T sirolimus, 37 TABLOID, 12 sitagliptin phosphate, 26 tacrolimus, 37, 42 sitagliptin/metformin, 26 tadalafil, 18 sitagliptin/metformin ext-rel, 26 tafluprost, 45 SKELAXIN, 24 TAGRISSO, 13 SKYLA, 29 tamoxifen, 12 SKYRIZI, 36 tamsulosin, 34 sodium picosulfate/magnesium oxide/citric acid, 33 TAPAZOLE, 31 sodium zirconium cyclosilicate, 31 tapentadol, 8 sofosbuvir/velpatasvir, 11 tapentadol ext-rel, 8 sofosbuvir/velpatasvir/voxilaprevir, 11 TARGRETIN, 13 solifenacin, 34 TARKA, 14 SOLIQUA, 26 tazarotene, 41 SOLIRIS, 35 TEGRETOL, 19 solriamfetol, 24 TEGSEDI, 31 somatropin, 30 TEKTURNA HCT, 17 SOMATULINE DEPOT, 25 telmisartan, 15 sonidegib, 13 telmisartan/hydrochlorothiazide, 15 SOOLANTRA, 43 temazepam, 22 SORIATANE, 41 TEMIXYS, 10 sotalol, 15 TEMODAR, 12 SPIRIVA, 38 TEMOVATE, 42, 43 spironolactone, 14 temozolomide, 12 spironolactone/hydrochlorothiazide, 17 tenofovir alafenamide, 11 SPRYCEL, 12 tenofovir disoproxil fumarate, 10 STALEVO, 21 terazosin, 14 stavudine, 10 terbinafine tabs, 9 STELARA INTRAVENOUS, 36 terbutaline, 39 STELARA SUBCUTANEOUS, 36 terconazole, 34 STIOLTO RESPIMAT, 38 teriflunomide, 23 STIVARGA, 13 teriparatide, 28 STRATTERA, 22 TESSALON, 39 STRIBILD, 10 testosterone cypionate, 25 STRIVERDI RESPIMAT, 39 testosterone enanthate, 25 STROMECTOL, 11 testosterone gel, 25 SUBSYS, 8 testosterone nasal gel, 26 sucralfate tablet, 34 testosterone soln, 25 sucroferric oxyhydroxide, 31 testosterone transdermal, 26 sulfacetamide lotion 10%, 41 tetrabenazine, 23 sulfacetamide oint 10%, 44 tetracycline, 9 sulfacetamide soln 10%, 44 thalidomide, 13 sulfacetamide/prednisolone phosphate 10%/0.25%, 44 THALOMID, 13 sulfamethoxazole/trimethoprim, 11 theophylline ext-rel tabs, 40 sulfamethoxazole/trimethoprim DS, 11 thioguanine, 12 sulfasalazine, 33 thiothixene, 22 sulfasalazine delayed-rel, 33 tiagabine, 19 sulindac, 7 TIAZAC, 17 sumatriptan, 23 ticagrelor, 35 sumatriptan inj, 23

TIGAN, 32 triptorelin pamoate, 28 TIKOSYN, 15 TRIUMEQ, 9 timolol maleate gel, 44 trospium, 34 timolol maleate soln, 44 trospium ext-rel, 34 timothy grass pollen allergen extract, 36 TRULICITY, 26 tinidazole, 11 TRUSOPT, 44 tiotropium, 38 TYMLOS, 28 tiotropium/olodaterol, 38 TYSABRI, 23 TIVICAY, 10 U tizanidine tabs, 24 UBRELVY, 23 TOBRADEX, 44 ubrogepant, 23 tobramycin, 44 umeclidinium/vilanterol, 38 tobramycin inhalation soln, 39 upadacitinib, 36 tobramycin/dexamethasone oint 0.3%/0.1%, 44 UPTRAVI, 18 tobramycin/dexamethasone susp 0.3%/0.1%, 44 UROCIT-K, 34 TOBREX, 44 URSO, 32 tofacitinib, 36 ursodiol, 32 tofacitinib ext-rel, 36 ustekinumab, 36 TOLAK, 41 tolterodine, 34 V tolterodine ext-rel, 34 VAGIFEM, 31 TOPAMAX, 20 valacyclovir, 11 topiramate, 20 valbenazine, 23 topotecan caps, 13 valganciclovir, 10 torsemide, 17 VALIUM, 19 TOUJEO, 26 valproic acid, 19 TOVIAZ, 34 valsartan, 15 tramadol, 8 valsartan/hydrochlorothiazide, 15 tramadol ext-rel tablet, 8 VALTOCO, 19 trandolapril, 14 VANCOCIN, 11 trandolapril/verapamil ext-rel, 14 vancomycin caps, 11 tranylcypromine, 20 varenicline, 25 trastuzumab-anns, 12 VASCEPA, 16 trastuzumab-qyyp, 12 VASERETIC, 14 travoprost, 45 VASOTEC, 14 TRAZIMERA, 12 VELCADE, 13 trazodone, 21 VELPHORO, 31 TRELEGY ELLIPTA, 38 VELTASSA, 31 TREMFYA, 36 VEMLIDY, 11 treprostinil, 18 venlafaxine, 20 treprostinil ext-rel, 18 venlafaxine ext-rel, 20 TRESIBA, 26 verapamil ext-rel, 17 tretinoin, 41 VFEND, 9 tretinoin - Avita, 41 VIBERZI, 33 tretinoin caps, 13 VIBRAMYCIN, 9 tretinoin gel microsphere, 41 VICTOZA, 26 TREXALL, 12 vigabatrin, 20 triamcinolone acetonide crm 0.5%, 42 VIGAMOX, 44 triamcinolone acetonide crm, lotion 0.025%, 42 VIMPAT, 19 triamcinolone acetonide crm, lotion, oint 0.1%, 42 VIOKACE, 33 triamcinolone paste, 43 VIREAD, 10 triamterene, 18 vismodegib, 13 triamterene/hydrochlorothiazide, 17 vitamin ADC/fluoride drops, 38 TRIBENZOR, 15 vitamin ADC/fluoride/iron drops, 38 trientine, 35 voriconazole, 9 trifluoperazine, 22 vorinostat, 13 trifluridine, 44 vortioxetine, 20 trifluridine/tipiracil, 12 VOSEVI, 11 trihexyphenidyl, 21 VOTRIENT, 13 TRIJARDY XR, 27 VRAYLAR, 21 TRILEPTAL, 19 VUMERITY, 23 TRILIPIX, 16 VYTORIN, 16 trimethobenzamide, 32 VYVANSE, 22 trimethoprim, 11 W TRINTELLIX, 20 warfarin, 35 TRIPTODUR, 28

X ZEJULA, 13 XALATAN, 45 ZEMBRACE SYMTOUCH, 23 XARELTO, 35 ZEMPLAR, 30 XCOPRI, 19 ZENPEP, 33 XELJANZ, 36 ZEPOSIA, 23 XELJANZ XR, 36 ZESTRIL, 14 XELODA, 12 ZIAC, 17 XIFAXAN, 11 zidovudine, 10 XIGDUO XR, 27 ZIEXTENZO, 35 XIIDRA, 45 ZIOPTAN, 45 XOLAIR, 40 ziprasidone, 21 XOSPATA, 13 ZIRABEV, 12 XTAMPZA ER, 8 ZITHROMAX, 9 XTANDI, 12 ZOCOR, 16 XULTOPHY, 26 ZOFRAN, 32 ZOLINZA, 13 Y zolmitriptan, 23 YONSA, 12 zolmitriptan nasal spray, 23 YUPELRI, 38 zolpidem, 22 Z zolpidem ext-rel, 22 zafirlukast, 39 ZOMIG, 23 ZANAFLEX, 24 zonisamide, 19 zanamivir, 11 ZUBSOLV, 24 ZARONTIN, 19 ZYCLARA, 41 ZYPREXA, 21